OPERATIVE  SURGERY 


01^  THE  CADAVER 


BY 

JASPER  JEWETT  GARMANY, 

A.  M.,    M.  D,,    F.  E.  C.  S., 

/TTENDING  SURGEON  TO   OUT-DOOR  POOR  DISPENSARY   OF  BELLEVUE   HOSPITAL; 

VISITING   SURGEON  TO  NINETT-NINTH   STREET  RECEPTION   HOSPITAL, 

BRANCH   OP   BELLEVUE    HOSPITAL;    MEMBER    OF    THfi 

BRITISH  MEDICAL  ASSOCIATION,  ETC. 


NEW  YORK 
D.    APPLETON    AND    COMPxilTY 

1887 


Lt: 


(^18 
IB81 

c.l 


Copyright,  1887, 
By   D.  APPLETON  AND  COMPANY. 


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CD 


m   MEMOEIAM.  \ 

TO     MY     PRECEPTOE, 

Professor  JAMES  R.  WOOD,  M.  D.,  LL.  D., 

IN   RECOGNITION   OF 

HIS   ACTS  OF  KINDNESS  DURING  MY  THREE  YEAES'  PUPILAGE, 

AND    WHILE     INTERNE     OF    BELLEVUE     HOSPITAL, 

THIS  VOLUME   IS    REVERENTLY   DEDICATED 

BY  THE  AUTHOR. 


PEEFAOE. 


It  is  my  endeavor  to  present  a  guide  to  the 
manipulative  procedures  of  the  ordinary  surgical 
operations. 

Acknowledgment  of  indebtedness  is  chiefly  due 
to  Stephen  Smith's  "  Operative  Surgery." 

New  Yoek  City,  Se'pteviber,  1887. 


CONTENTS. 


PAGE3 

CHAPTER  I. 

Use  of  Specula,  Catheters,  Sounds,  Bougies,  etc. — Plugging  op 
Posterior  Nares. — I.  Aural,  Nasal,  Vaginal,  and  Rectal  Spec- 
ula— II.  Catheterization  of  Eustachian  Tube,  Kasal  Duct ; 
Catheterization  of  Larynx  ;  Intubation  of  Larynx  ;  Use  of 
Stomach-Tube,  (Esophageal  Probang,  Urethral  Sound  or  Cath- 
eter, Rectal  Bougies — III.  Plugging  of  Posterior  Nares    .        .  1-9 

CHAPTER  IL 

Paracentesis,  Hypodermic  Needle. — I.  Corneee,  Tympani,  Thora- 
cis, Pericardii,  Abdominis,  Vesicae,  Urethrse,  Aspiration — II. 
Hypodermic  Needle 10-16 


CHAPTER  III. 

Manipulation  of  the  Scalpel — Incisions— Drainage — Sutures — 
Knots 17-27 


CHAPTER  IV. 

Operations  on  the  Head  and  Neck. — Trephining — Operation  for 
Strabismus — Excision  of  the  Eye — Extraction  of  Teeth — Per- 
foration of  the  Antrum  —  Excision  of  the  Tongue  —  Bron- 
chotoray — ^External  (Esophagotomy      .        ,        .        .        .  28-42 

CHAPTER  V. 

Operations  on  the  Trunk:. — Excision  of  the  Mammary  Gland — 
Median  Laparotomy — Enterorrhaphy — Enterectomy — Enter- 
otomy  —  Enterostomy —  Colectomy  —  Colostomy  —  Nephror- 
rhaphy — Nephrotomy — Nephrectomy — Symphysiotomy       ,  4E-53 


yiii  CONTENTS. 


OPIAFTER  VI. 


Genito- Vesical. — External  Perineal  Uretlirotomy — Sounding  for 
Vesical  Calculus — Lithotrity — Cystotomy — Posterior  Catheter- 
ization— Resection  of  the  Scrotum — Circumcision — Amputa- 
tion of  the  Penis — Shortening  of  the  Round  Ligaments — Cas- 
tration— Oophorectomy         .......  54—66 

CHAPTER  VII. 

Operations  on  Muscles. — Manipulation  of  the  Tenotome — Myoto- 
my (Tenotomy  and  Fasciatomy) — Suturing  of  Tendons: — Ster- 
no-cleido-Mastoid ;  Flexors  of  Digits ;  Extensors  of  Digits ; 
Flexors  of  Carpus ;  Biceps  Cubiti ;  Flexors  of  Toes;  Extensor 
Loiigus  Digitorum  ;  Extensor  Proprius  Hallucis ;  Tibialis  Anti- 
cus ;  Tibialis  Posticus ;  Peroneus  Longus  and  Brevis ;  Tendo 
Achillis ;  Biceps  Femoris ;  Inner  Hamstrings ;  Quadriceps 
Femoris;  Adductor  Longus;  Plantar  Fascia — Suturing  of  the 
Tendon  of  the  Biceps  Femoris 67-72 

CHAPTER  VIII. 

Opeeations  on  Neeyes.  —  Neurotomy  —  Neurectomy  —  Nerve- 
Stretching — Nerve-Suturing — Neurotomy  of  Lingual— Neurec- 
tomy of  Spinal  Accessory — Stretching  of  Great  Sciatic — Sutur- 
ing of  Median 73-75 

CHAPTER  IX. 

Operations  on  the  Circulatory  System. — Compression  of  Ves- 
sels (Tourniquet  and  Elastic  Band) — Torsion  of  Vessels— Liga- 
ture :  {a)  Cut  Vessels,  (h)  Vessels  in  their  Continuity — Ligature 
of  Special  Arteries  in  their  Continuity : — Radial,  Ulnar,  Bra- 
chial, Axillary,  Subclavian,  Vertebral,  Common  Carotid,  Inter- 
nal Carotid,  External  Carotid,  Superior  Thyroid,  Lingual,  Facial, 
Occipital,  Temporal,  Common  Iliac,  Internal  Iliac,  Gluteal, 
Sciatic,  Internal  Pudic,  External  Iliac,  Deep  Epigastric,  Femoral, 
Profunda  Femoris,  Popliteal,  Posterior  Tibial,  Peroneal,  An- 
terior Tibial,  Dorsalis  Pedis — Phlebotomy — Arteriotomy  — 
Transfusion 76-102 

CHAPTER  X. 

Opeeations  on  the  Osseous  System. — Manipulation  of  the  Saw — 
Osteotomy  (Tibia) — Wiring  of  Bones  (Patella) — Excision  of 


CONTENTS,  ix 

PAGES 

Superior  Maxilla — Excision  of  Inferior  Maxilla — Resection  of 
Eib — Resection  of  Articulating  Ends  of  Bones: — Shoulder,  El- 
bow, Wrist,  Metacarpo-Phalangeal,  Phalangeal,  Hip,  Knee, 
Ankle 103-121 

CHAPTER  XI. 

Amputations  and  Disakticulations. — Manipulation  of  the  Ampu- 
tating-Knife — Steps  in  Operating — I.  Amputations  and  Disar- 
ticulations of  the  Upper  Limb :  Fingers ;  Wrist  (Dubreuil's 
Operation) ;  Forearm  ;  Elbow ;  Arm ;  Shoulder  (Spence's 
Operation)  —  II.  Amputations  and  Disarticulations  of  the 
Lower  Limb:  Toes;  Metatarsus  (Lisfranc's  Operation) ;  Tarsus 
(Chopart's  Operation) ;  Ankle  (Syme's  Operation),  (Pirogoff's 
Operation) ;  Leg  (Teale's  Operation) ;  Knee  (Bauden's  Opera- 
tion); Thigh  (Garden's  Operation),  (Gritti's  Operation),  (Lis- 
ter's Operation) ;  Hip  (Liston's  Operation),  (Jordan's  Opera- 
tion)    122-146 


OPERATIYE  SURGERY  0^  THE  CADAYER. 


CHAPTER  I. 

USU    OF  SPECULA,    CATHETERS,    SOUNDS,   BOUGIES,    AND 
PLUGGING    OF  POSTERIOR  NARES. 

I.    INTEODUCTIOi!^    OF    AURAL,    NASAL,    VAGIXAL,    AND 
RECTAL    SPECULA. 

Aural  Specidum  (Gruber,  Toynbee). — Before  tlie 
speculum  can  be  introduced,  the  canal  must  be 
straightened  by  seizing  the  auricle  by  its  upper  part 
and  drawing  it  upward,  backward,  and  outward. 

Moisten  the  speculum  with  water,  and  gently 
insert  the  small  end  into  the  canal.  The  speculum 
is  to  be  introduced  into  the  canal  to  the  required 
extent  by  gently  screwing  it  forward  and  backward 
in  a  small  arc,  and  by  slight  pressure. 

To  examine  the  drum,  it  is  best  to  use  reflected 
light.  The  s]3eculum  must  be  manipulated  to  bring 
the  different  parts  of  the  canal  and  of  the  drum  into 
view. 

An  ear-syringe  must  have  its  nozzle  introduced  in 
the  same  manner  as  the  speculum.  Apply  the  nozzle 
to  the  roof  of  the  canal  while  injecting  the  fluid. 

Nasal  Speculum  (Fraenkel). — Insert  the  specu- 
lum along  the  floor  of  the  naris,  having  first  pushed 


2  OPERATIVE  SURGERY  ON  THE  CADAVER. 

up  tlie  tip  of  the  nose  to  straighteii  tlie  canal.     The 
floor  of  the  naris  extends  horizontally  backward. 

When  the  speculum  has  been  introduced  to  the 
extent  of  one  to  one  and  a  half  inch,  the  blades  are 
to  be  separated  by  the  screw. 

Both  nostrils  may  be  dilated  at  once  by  putting 
one  blade  of  the  speculum  on  each  side  of  the  septum, 
and  then  separating  them. 

Vaginal  Speculmn  (Fergusson,  Sims). — Place  the 
subject  on  the  back,  with  the  hip- joints  and  knees 
semiflexed  and  the  thighs  separated,  in  order  to  use 
the  ordinary  specula.  Lubricate  the  cylindrical  spec- 
ulum (Fergusson).  Press  the  posterior  edge  of  the 
vaginal  entrance  downward  with  the  convex  side  of 
the  tip  of  the  instrument.  Push  the  speculum  hori- 
zontally to  examine  the  canal  and  manipulate  to  bring 
into  view  the  cervix. 

Place  the  subject  on  the  left  side  with  the  left 
arm  drawn  posteriorly  so  that  she  rests  upon  the 
left  chest-wall ;  flex  the  thighs  and  legs  to  about  a 
right  angle.  The  right  knee  rests  above  the  left,  so 
that  the  right  hip-joint  is  more  flexed  than  the  left. 
Lubricate  the  blade  of  Sims's  speculum  which  is  to 
be  introduced.  Grasp  the  isthmus  of  the  instrument 
between  the  fingers  and  thumb  of  the  left  hand,  and 
let  the  blade  to  be  introduced  rest  in  the  concavity 
of  the  extended  thumb  and  index-finger  of  the  right 
hand  with  the  pulp  of  the  index-finger  extending  be- 
yond the  lip  of  the  instrument.  The  right  forefin- 
ger is  thus  in  the  concavity  of  the  blade  to  be  intro- 
duced. Press  against  the  posterior  wall  of  the  vagina 
with  the  back  of  the  right  index-finger  and  guide  the 
blade  into  the  vagina  with  the  convexity  toward  its 


USE  OF  SPECULA.  3 

posterior  and  superior  lateral  wall.  Tlie  walls  of  tlie 
vagina  are  separated,  allowing  air  to  distend  the  canal. 

To  liold  the  speculum,  the  assistant  must  stand 
behind  the  body  and  use  the  width  of  his  hand  like 
a  wedge  betAveen  the  buttock  and  upper  blade  of 
the  speculum.  The  isthmus  lies  against  the  palm 
of  the  hand,  and  the  superior  part  between  the  in- 
dex-linger and  thumb,  leaving  the  other  fingers  free. 

An  instrument  to  depress  the  vaginal  folds  ob- 
structing the  view  may  be  necessary. 

Hectal  Speculum. — Place  the  subject  on  the  back 
mth  the  thighs  separated ;  or  on  the  side  with  the 
knees  pushed  up  close  to  the  abdomen.  A  reflecting 
cylindrical  speculum  with  a  portion  of  its  circumfer- 
ence deficient,  or  one  of  the  valve  specula,  may  be 
used.  Lubricate  the  point  of  the  instrument.  Insert, 
directing  the  point  of  the  instrument  toward  the 
bladder,  hence  somewhat  forward,  for  the  first  inch 
and  a  half.  Now  the  point  of  the  instrument  is  to 
be  directed  nearly  horizontally  backward,  toward  the 
hollow  of  the  sacrum. 

If  a  valve-speculum  is  used,  it  is  to  be  opened,  after 
it  is  fully  introduced,  and  again  shut  before  beginning 
to  be  removed.  Manipulate  the  speculum  to  bring 
into  view  every  part. 

The  nozzle  of  a  syringe  must  follow  this  same 
course  durino^  its  introduction. 

n.  CATHETERIZATIO]^  OF  EUSTACHIAIS"  TUBE,  IS^ASAL  DUCT  ; 
rr^TUBATIOoN^  OF  TRACHEA  ;  USE  OF  STOMACH-TUBE, 
(ESOPHAGEAL  PEOBAIN^G,  URETHEAL  SOUND  OR  CATHE- 
TER, RECTAL  BOUGIES. 

MistacJiian  Catheter  (Noyes). — Pass  the  catheter, 
keeping  its  point  against  the  floor  of  the  naris  until 


4  OPERATIVE  SURGERY  ON   THE  CADAVER. 

it  reaches  the  pharynx.  Push  the  catheter  until  it 
touches  the  posterior  wall  of  the  pharynx  ;  withdraw 
the  instrument  about  one  half  of  an  inch,  and  direct 
its  point  outward  and  slightly  upward  toward  the 
corresponding  ear,  touching  the  side  wall  of  the  phar- 
ynx. A  sensation,  as  if  the  catheter  is  grasped,  is 
felt  when  its  point  engages  in  the  orifice  of  the  canal. 
Generally  the  opening  is  sought  for  too  far  posteri- 
orly. The  catheter  may  be  passed  from  the  opposite 
nostril,  or  from  the  mouth. 

Confii-m  the  introduction,  if  desirable,  by  using  the 
otiscope,  to  hear  the  rush  of  air  when  forced  through 
the  catheter  into  the  tympanum. 

Prohing  of  the  Nasal  Duct — Pull  down  the  lower 
lid  to  expose  the  punctum  with  the  orifice  of  the 
lower  canaliculus.  Introduce  a  small  silver  probe 
pei"pendicularly,  into  the  orifice  and  then  turn  its  point 
horizontally  inward,  following  the  canal  until  it 
touches  the  inner  bony  wall  of  the  lachrymal  sac. 
The  point  is  now  directed  downward  almost  perpen- 
dicularly, with  a  slight  inclination  backward  and  out- 
ward, and  advanced  until  it  appears  in  the  inferior 
meatus  of  the  corresponding  nostril.  The  canal  trav- 
ersed is  about  an  inch  in  length. 

CatJieterism  of  the  Larynx. — The  mouth  is  held 
open  by  means  of  a  mouth-gag  if  necessary.  With  the 
left  index-finger  passed  back  to  the  root  of  the  tongue, 
feel  and  hook  forward  the  epiglottis.  Pass  the  cathe- 
ter, keeping  its  beak  against  the  finger,  until  it 
reaches  the  epiglottis.  Direct  the  beak  of  the  cathe- 
ter over  the  epiglottis,  and  down  its  posterior  sur- 
face into  the  larynx. 

Intiihationofthe  Larynx. — Direct  O'Dwyer's  tube 


CATHETERS,   SOUNDS,   AND  BOUGIES.  5 

of  suitable  size  by  the  foregoing  manipulations  into 
the  larynx.  Push  the  tube  loose  from  the  obturator, 
and  sink  it  down  into  the  larynx  until  the  epiglottis 
can  close  over  its  opening.  A  piece  of  thread  passed 
through  the  opening  in  the  anterior  angle  of  the  tube, 
and  out  of  the  mouth,  prevents  its  descent  into  the 
oesophagus  if  the  introduction  has  been  faulty.  With- 
draw the  thread,  if  the  tube  has  been  correctly  intro- 
duced, holding  the  finger  against  the  tube  to  prevent 
the  thread  drawing  upon  it. 

To  withdraw  the  tube,  the  extractor  is  guided  into 
the  opening  in  the  tube,  and  its  blades  separated,  to 
hold  it  finnly.  It  can  now  be  removed,  keeping  the 
blades  of  the  extractor  separated  during  the  removal. 

Stomach-Tube^  CEsopJiageal  Prohang,  or  Bougie, 
— Push  the  head  of  the  subject  back  so  as  to  make 
the  canal  to  be  traversed  as  straight  as  possible. 
Pass  the  tube,  probang,  or  bougie,  to  the  posterior 
wall  of  the  pharynx.  Place  the  left  index-finger  so 
as  to  protect  the  larynx,  until  the  instrument  has 
been  directed  down  the  oesophagus  along  the  poste- 
rior pharyngeal  wall  for  several  inches.  Remove  the 
finger  from  the  mouth.  Bend  the  head  forward  to 
make  a  curve  in  the  cervical  region  corresponding  to 
the  dorsal  curve.  Gently  introduce  about  eighteen 
inches  of  tubing  when  the  stomach  will  be  entered. 

The  oesophageal  probang  is  introduced  beyond 
the  body  to  be  removed,  when  the  bristles  are  spread 
and  the  body  drawn  up. 

If  the  tube  is  passed  through  the  nostril,  give  it  a 
slight  bend  downward,  so  that,  when  it  meets  the  poste- 
rior wall  of  the  pharynx,  it  will  be  directe'd  downward. 

Catheterization  of  the   Urethra. — To  pass  a  cathe- 


6-  OPERATIVE  SURGERY  ON   THE  CADAVER. 

ter  or  sound  tlirougli  the  male  uretlira,  the  body 
must  be  laid  on  the  back,  the  shoulders  elevated,  and 
the  hip-joints  slightly  flexed  and  rotated  outward,  the 
thighs  being  separated.  Stand  on  the  left  side  facing 
the  head  of  the  subject,  and  grasp  the  penis  behind 
the  corona  glandis  between  the  middle  and  ring  fin- 
gers of  the  left  hand  with  the  palm  turned  upward. 
Separate  the  lips  of  the  meatus  with  the  left  thumb 
and  index-finger,  and  raise  the  penis.  Hold  lightly 
by  its  extremity  the  oiled  catheter  or  sound  between 
the  right  thumb  and  index  and  middle  fingers.  Enter 
the  beak  of  the  instrument  into  the  meatus,  keeping 
the  handle  depressed  and  the  shaft  horizontally  lying 
over  the  left  groin.  By  pulling  the  penis  over  the 
instrument  thus  held,  with  slight  pressure,  it  will  be 
*^  swallowed  "  until  its  beak  is  below  the  pubes.  Re- 
volve the  shaft  of  the  instrument  horizontally  until 
it  occupies  the  median  plane  of  the  body  lying  on  a 
line  which  would  run  from  the  umbilicus  to  the  sym- 
physis pubis.  The  beak  being  fairly  engaged  under 
the  symphysis,  begin  to  raise  the  handle  of  the  instru- 
ment, supporting  more  than  its  weight,  so  that  the 
beak  will  follow  the  roof  of  the  canal.  The  left  in- 
dex-finger can  support  the  convexity  of  the  instru- 
ment by  pressure  over  it  through  the  rectal  wall  or 
perinseum.  The  handle  is  made  to  revolve  through 
a  semicircle  in  the  vertical  plane  running  through 
the  median  line  of  the  body.  While  the  handle  is 
being  depressed  between  the  thighs,  the  finger  sup- 
porting the  convexity  makes  the  beak  of  the  in- 
strument continue  to  follow  the  roof  of  the  canal. 
If  the  beak  circles  around  the  shaft  when  turned, 
the  catheter  is  in  the  viscus. 


CATHETERS,   SOUI^DS,   AND  BOUGIES.  7 

On  a  fat  subject  tlie  tour  du  madre  is  conve- 
nient. The  body  is  placed  as  before,  but  the  op- 
erator stands  on  the  right  side  facing  the  head  of 
the  subject  The  handle  of  the  instrument  may  be 
held  between  the  thighs,  or  over  the  left  thigh,  with 
the  shaft  lying  horizontally.  The  instrument  is  in- 
troduced as  before  until  the  beak  reaches  the  bulb, 
when  the  handle  is  made  to  describe  an  arc  toward 
the  umbilicus,  being  continually  raised  until  the  me- 
dian vertical  plane  is  reached,  when  it  is  depressed 
as  before  between  the  thighs. 

To  introduce  rubber  catheters  requires  no  manipu- 
lative skill. 

Tunneled  Sounds  and  Catheters, — These  are  in- 
troduced upon  a  guide  of  rubber  or  whalebone.  In- 
ject so  as  to  distend  with  oil  the  urethra.  Introduce 
a  filiform  bougie,  avoiding  the  lacunae,  on  the  roof  of 
the  urethra,  for  the  first  inch.  If  it  is  arrested,  inti'o- 
duce  another,  and  so  on  until  six  or  eight  are  intro- 
duced. Alternate  the  ends  introduced — first  straight, 
then  spiral  and  angular.  By  withdi'awing  and  then 
advancing  mth  a  screwing  motion,  one  of  the  bunch 
will  enter  the  bladder ;  ^^dthdraw  the  others.  The 
protruding  end  is  now  threaded  through  the  tunnel 
of  the  catheter,  and  held  firmly  between  the  left 
thumb  and  index-finger.  The  sound  is  made  to  fol- 
low the  same  manoeuvres  as  the  ordinary  sound,  but 
is  guided  by  the  filiform  bougie,  without  force,  into 
the  bladder. 

To  catheterize  the  female  urethra,  turn  the  subject 
on  the  back,  semiflex  the  hip  and  knee  joints,  and 
separate  the  thighs.  Stand  on  the  right  side,  facing 
the  head  of  the  subject.      Hold  the  oiled  catheter 


8  OPERATIVE  SURGERY  ON  THE  CADAVER. 

near  its  beak  between  the  right  thumb  and  index- 
finger,  overlapping  its  end  with  the  index-finger. 
Pass  the  hand  holding  the  catheter  under  the  right 
knee,  and  separate  the  labia  with  the  index-finger 
from  below  upward,  until  the  upper  edge  of  the 
vagina  is  felt.  Feel  for  the  prominent  urethral  pa- 
pilla, about  one  half  of  an  inch  above  this,  and  place 
the  pulp  of  the  index-finger  at  its  lower  border. 
The  catheter  can  now  be  easily  guided  over  the  pulp 
of  the  finsrer  into  the  urethra  and  on  into  the  blad- 
der.  It  may  ba  necessary  to  follow  the  cord-like  ure- 
thra, felt  through  the  anterior  vaginal  wall,  up  to  the 
papilla. 

If  a  soft  catheter  is  used,  pass  the  left  hand  over 
the  thigh,  to  aid  in  its  introduction. 

Introduction  of  Rectal  Bougies. — Place  the  sub- 
ject on  the  back  with  the  knees  and  hip-joints  flexed, 
and  the  buttock  at  the  edge  of  the  table ;  or  on  the 
side  with  the  hip- joints  and  knees  semiflexed.  Gently 
enter  the  oiled  point  of  the  bougie  into  the  anal  ori- 
fice, inclining  it  slightly  forward.  Direct  the  point 
for  the  first  inch  and  a  half  forward  toward  the  blad- 
der. Now  introduce  the  bougie  until  fvvQ  inches 
have  entered  the  rectum  with  the  point  directed 
nearly  horizontally  toward  the  middle  of  the  sacrum. 
If  the  bougie  is  to  be  further  introduced,  its  point 
should  be  directed  a  little  forward  and  to  the  left,  as 
if  to  strike  the  abdominal  wall  two  inches  to  the  left 
of  the  umbilicus. 

III.    PLUGGING    THE    POSTERIOR    NAIIES. 

Place  the  subject  on  the  back  with  the  head 
slightly  raised  upon  a  block.     Separate  the  jaws  by 


PLUGGING   THE  POSTERIOR  NARES.  9 

means  of  a  moutli-gag.  Prepare  a  firm  plug  of  cot- 
ton or  cloth,  one  half  of  an  inch  thick  and  three 
quarters  of  an  inch  long,  and  tie  it  in  the  middle  of 
a  doubled  cord  eighteen  inches  long.  Pass  a  Bellocq's 
sound  threaded  mth  a  cord  a  foot  long,  keeping  its 
beak  applied  to  the  floor  through  the  naris,  until  it 
reaches  the  pharynx.  Protrude  the  spring  from  the 
canula,  and  the  eye  carrying  the  cord  will  be  curved 
into  the  mouth.  Attach  to  this  cord  one  end  of  the 
doubled  cord  attached  to  the  plug,  while  the  other 
end  of  the  doubled  cord  may  be  cut  until  it  meas- 
ures six  inches  in  length.  Draw  the  spring  into  the 
canula,  which  will  pull  the  oiled  plug  into  the  mouth. 
Now  begin  to  withdraw  the  Bellocq's  sound,  direct- 
ing, if  necessary,  the  plug  up,  around,  and  over  the 
soft  palate,  mth  the  left  index-finger. 

Detach  the  end  of  the  doubled  cord  protruding 
from  the  nostril,  and  separate  it  so  that  there  will  be 
two  strings.  Now  stuif  into  the  nostril  between  the 
two  strings  a  plug  of  cotton,  over  which  tie  the 
strings,  thus  holding  in  place  this  anterior  plug.  Care 
must  be  taken  not  to  pull  the  posterior  plug  too  far 
into  the  nostril.  It  must  only  engage  itself  in  the 
posterior  naris.  The  other  end  of  the  doubled  cord 
hangs  do^vn  into  the  pharynx. 

To  remove  the  plugs,  cut  the  string  holding  the 
anterior  plug  and  withdraw  this  plug.  Catch  with 
forceps  the  end  of  the  doubled  cord  hanging  in  the 
pharynx  and  draw  gently  upon  the  posterior  plug. 
The  detachment  of  the  posterior  plug  may  be  aided 
by  a  probe  passed  through  the  anterior  naris,  press- 
ing it  backward  into  the  pharynx. 


CHAPTER  11. 

PARACENTESIS. 

I.    COKNE^,  TYMPANI,  THOEACIS,  PEEICAEDII,  ABDOMIl^IS^ 
VESICAE  ;    ASPIEATION.       II.    HYP0DEE3IIC  I^EEDLE. 

Paracentesis  Corneoe. — Place  tlie  subject  on  tlie 
back,  and  stand  behind  the  bead.  Raise  the  upper 
lid  of  tbe  eye,  and  apply  tbe  pulp  of  the  left  index- 
finger  horizontally  to  tbe  lid  and  partly  to  tbe  globe. 
Depress  tbe  lower  lid,  and  apply  tbe  middle  finger 
of  tbe  same  band  in  like  manner.  Now  by  pressure, 
keeping  tbe  fingers  apart,  tbe  globe  of  tbe  eye  is 
controlled. 

Tbe  puncture  is  made  witb  a  broad  needle  beld 
ligbtly  between  tbe  rigbt  thumb  and  index-finger. 
Enter  the  needle  with  its  flat  surface  parallel  to  tbe 
iris  at  either  lower  lateral  margin  of  the  cornea,  and 
direct  the  point  downward  as  if  to  puncture  the 
lower  margin  a  little  beyond  its  central  point.  The 
needle  must  never  be  passed  in  front  of  tbe  pupil  in 
traversing  the  anterior  chamber.  While  withdrawing, 
rotate  the  needle  as  soon  as  its  point  has  left  the 
anterior  chamber,  in  order  to  make  the  wound  patu- 
lous. 

Paracentesis  Tympani.  —  Expose  the  tympanic 
membrane  by  reflected  light  through  an   ear-specu- 


PARACENTESIS.  H 

lum.  Puncture  tlie  tympanum  posterior  to  tlie  han- 
dle of  the  malleus  Math  a  small,  double-edged  knife, 
held  between  the  right  thumb  and  index-linger.  En- 
large the  puncture  vertically,  not  allowing  the  point 
of  the  knife  to  scarify  the  inner  wall  of  the  tym- 
panum. 

Paracentesis  Thoracis. — Prepare  the  subject  for 
this  and  the  following  paracenteses  by  injecting 
water  into  the  cavities. 

Place  the  subject  on  the  side.  Find  the  sixth 
intercostal  space,  and  select  a  point  just  above  the 
lower  rib  bounding  this  space  equidistant  from  the 
sternum  and  from  the  spine.  Puncture  with  a  lancet 
the  s.kin  at  this  spot.  Enter  the  trocar  and  canula 
in  this  puncture  and  push  through  the  thoracic  wall, 
determining  to  what  extent  the  instrument  shall  be 
introduced  by  the  right  index-finger  laid  along  the 
Tipper  surface  of  the  instrument.  Direct  the  point 
of  the  instrument  upward  to  avoid  the  upper  edge  of 
the  lower  rib.  Withdraw  the  trocar.  The  fluid  may 
be  allowed  to  run  away,  or  it  can  be  removed  by 
suction.  The  intercostal^  space  sinks  below  the 
puncture  through  the  skin  as  the  fluid  is  removed. 

Keep  the  integument  pushed  against  the  shaft  of 
the  instrument,  in  order  to  close  the  puncture  imme- 
diately after  it  is  withdrawn. 

If  a  lower  intercostal  space  be  chosen,  be  careful 
to  direct  the  point  of  the  trocar  upward,  to  avoid 
puncturing  the  diaphragm. 

Paracentesis  Pericardii. — Puncture  the  skin  in 
the  center  of  the  flfth  intercostal  space  at  any  point 
three  quarters  of  an  inch  to  two  inches  from  the  bor- 
der of  the  sternum  on  the  left  side.     The  internal 


12  OPERATIVE  SURGERY  OR  THE  CADAVER. 

mammary  artery  is  situated  about  half  an  inch  from 
the  sternum.  Hold  the  trocar  and  canula  in  the 
rio;ht  hand  with  the  rio^ht  index-fino:er  laid  alons:  the 
instrument  to  prevent  its  entering  the  sac  any  greater 
distance  than  that  determined  upon.  Enter  the  point 
of  the  instrument  into  the  puncture  and  push  the 
instrument  upward  and  inward  into  the  sac  with 
great  care.  Withdraw  the  trocar  and  allow  the  fluid 
to  run  out,  or  to  be  sucked  out  through  the  canula. 
The  same  precautions  against  the  entrance  of  air,  on 
the  withdrawal  of  the  trocar,  must  be  taken  as  in 
paracentesis  thoracis. 

Paracentesis  AbdoTYimis. — Place  the  subject  in  the 
sitting  posture,  and  surround  the  abdomen  with  a 
broad,  many-tailed  bandage,  with  an  opening  through 
which  to  operate.  Make  a  puncture  through  the 
skin  with  a  lancet  at  the  point  bisecting  a  line  draw^n 
from  the  umbilicus  to  the  symphysis  pubis.  In  this 
puncture  enter  the  trocar  and  canula,  holding  the 
instrument  in  the  right  hand,  with  the  index-finger 
applied  to  its  upper  surface  where  you  wish  to  limit 
its  introduction.  Push  the  instrument  into  the  ab- 
dominal cavity.  Withdraw  the  trocar,  leaving  in  the 
canula  until  sufl&cient  fluid  has  escaped. 

The  canula  may  be  moved  about,  or  a  catheter- 
perforated  tube  introduced  through  the  canula,  to 
promote  the  evacuation  of  the  fluid ;  withdraw  the 
canula,  preventing  the  introduction  of  air. 

Paracentesis  Vesicce. — The  bladder  may  be  tapped 
above  or  below  the  pubes,  through  the  anterior  vagi- 
nal wall,  or  through  the  anterior  wall  of  the  male 
rectum. 

Suprapubic, — Place    the    subject    on   the   back; 


PARACENTESIS.  13 

puncture  witli  a  lancet  the  skin  just  above  tlie  sym- 
physis pubis.  Enter  the  trocar  and  canula  through 
the  puncture,  and  direct  its  point  downward  and 
backward,  while  pushing  it  into  the  bladder.  Limit 
the  introduction  of  the  instrument  to  about  an  inch ; 
and  if  a  curved  instrument  is  used,  keep  the  convexity 
uppermost.  Withdraw  the  trocar,  and  allow  the  fluid 
to  escape. 

While  withdrawing  the  canula,  close  its  orifice 
with  the  pulp  of  the  index-finger,  to  prevent  urine 
or  air  being  sucked  out  along  its  track.  Guard  against 
the  entrance  of  air,  as  in  the  other  paracenteses. 

Subpubic, — Pull  the  penis  down,  and  puncture  the 
skin,  just  under  the  symphysis  pubis  with  a  lancet. 
Enter  the  point  of  a  small  curved  trocar  and  canula, 
wdth  its  concavity  turned  upward,  into  the  puncture, 
and  push  the  instrument  directly  backward  through 
the  tissues  for  about  two  inches ;  withdraw  the  tro- 
car. After  the  urine  has  escaped,  withdraw  the 
canula,  with  the  same  precautions  as  in  the  previous 
puncture. 

Vaginal, — Place  the  subject  on  the  back  with  the 
thighs  and  legs  semiflexed  and  strongly  abducted. 
Stand  between  the  legs  and  introduce  into  the  vagina 
the  left  index-finger  with  its  palmar  surface  turned 
upward  until  its  tip  reaches  a  point  an  inch  posterior 
to  the  posterior  surface  of  the  pubis.  Shield  the  point 
of  a  curved  trocar  by  withdrawing  it  a  little  into 
the  canula.  Introduce  the  instrument  with  its  con- 
cavity turned  upward,  and  its  end  following  the  pal- 
mar surface  of  the  left  index-finger.  When  the  end 
reaches  the  tip  of  the  finger,  protrude  the  point  of 
the  trocar.     Push  the  instrument  upward  and  back- 


14  OPERATIVE  SURGERY  OJ^  TEE  CADAVER. 

ward  into  tlie  blaclcier ;  ^\atlidraw  the  trocar,  and  allow 
the  urine  to  flow.  In  order  to  prevent  the  escape  of 
urine  into  tlie  tissues,  take  the  same  precautions  as 
before,  while  removing  the  canula. 

llectcd. — Place  the  subject  in  the  lithotomy  posi- 
tion. Introduce  the  left  index-finger  into  the  rectum^ 
and  feel  for  the  prostate,  and  then  feel  beyond  a  space 
bounded  on  each  side  by  the  cord-like  vesiculse  semi- 
nales  converging  toward  the  prostate.  Introduce  a 
curved  trocar  and  canula  with  the  convexity  down- 
ward, and  the  point  of  the  trocar  sheathed  in  the 
canula,  along  the  palmar  surface  of  the  finger  until 
the  end  of  the  canula  is  applied  to  the  anterior  rectal 
wall  just  beyond  the  prostate  in  the  median  line.  Pro- 
trude the  point  of  the  trocar,  and  push  the  instru- 
ment upward  into  the  bladder.  Do  not  allow  urine 
to  escape  from  the  canula  while  the  canula  is  being 
withdrawn. 

Paracentesis  Uretlirce. — Place  the  subject  in  the 
lithotomy  position.  Introduce  the  left  index-finger 
into  the  rectum,  and  apply  the  pulp  of  the  finger  to 
the  rectal  wall  where  the  anterior  extremity  or  apex 
of  the  prostate  is  felt.  With  a  double-edged  knife 
held  as  a  pen,  but  with  cutting  edges  held  vertically^ 
pierce  the  perlneeum  in  the  median  line  a  little  less  than 
an  inch  in  front  of  the  anus.  Push  the  knife  boldly 
forward,  directing  the  point  toward  the  tip  of  the  left 
index-finger.  The  knife  may  be  given  a  slight  up- 
and-down  motion  of  the  handle  to  enlarge  the  wound 
as  the  point  advances;  when  the  point  is  felt  to  be  near 
the  tip  of  the  finger,  by  directing  it  obliquely  to  the 
right  or  left,  the  urethra  is  opened. 

To  catheterize  through  this  puncture,  withdraw 


PARACENTESIS.  15 

the  knife  and  insert  a  director  into  the  bladder,  when 
the  left  index-finger  can  be  removed  from  the  rec- 
tum, and  the  left  hand  given  charge  of  the  director. 
On  the  director  guide  a  catheter  into  the  bladder. 

If  the  urethra  is  tapped  through  the  rectum,  the 
lateral  walls  of  the  rectum  may  be  held  apart  by  two 
Sims's  specula,  and  the  left  index-finger  must  direct 
the  point  of  the  knife  toward  the  apex  of  the  prostate. 

Aspiration  (Dieulafoy). — Draw  the  piston  back, 
producing  thus  a  vacuum  in  the  cylinder  of  the  in- 
strument. Grasp  the  needle  in  the  same  manner  as 
a  trocar,  and  push  it  through  the  skin  and  tissues 
into  the  cavity  to  be  explored.  If  its  use  is  substi- 
tuteel  for  the  trocar  and  canula,  the  direction  and 
situation  of  the  punctures  are  the  same  for  both  in- 
struments. By  drawing  the  skin  to  one  side  before 
making  the  puncture,  the  opening  in  the  skin  on  re- 
moving the  needle  will  not  correspond  with  the 
course  of  the  needle  through  the  deeper  tissues,  thus 
presenting  a  valvular  arrangement  against  the  entrance 
of  air.  After  the  opening  in  the  needle  is  buried  in 
the  tissues,  open  the  stop-cock,  which  will  cause  the 
vacuum  to  extend  into  the  needle.  Now  advance 
slowly,  "  vacuum  in  hand,''  in  search  of  the  effusion. 
As  soon  as  a  cavity  is  entered,  the  point  of  the  needle 
must  remain  stationary  until  the  needle  is  removed. 

II.    IIYPODEEMIC    IS^EEDLE. 

The  hypodermic  needle  should  always  be  made 
use  of  before  the  trocar  and  canula  as  a  means  of  diag- 
nosis. It  must  enter  the  same  spot,  and  have  its  point 
directed  as  that  of  the  trocar  in  the  various  tappings. 
Withdraw  the  piston  after  the  point  is  in  the  fluid. 


16  OPERATIVE  SURGERY  ON  THE  CADAVER. 

and  allow  the  syringe  to  fill.  The  needle  must  be 
withdrawn  quickly,  and  the  left  index-finger  placed 
immediately  over  the  point  of  puncture. 

If  the  needle  is  used  for  medication,  the  manipu- 
lation is  different.  Put  the  nozzle  of  the  syringe 
into  the  solution  to  be  injected,  and  withdraw  the 
piston  beyond  the  mark  denoting  the  required  num- 
ber of  minims.  Adjust  the  needle,  and  force  out  the 
superfluous  solution  and  air,  holding  the  syringe 
with  the  point  upward. 

If  the  medication  is  special,  the  point  of  the  needle 
is  introduced  to  the  spot,  and  the  syringe  slowly 
emptied.  If  the  medication  is  general,  the  skin  and 
areolar  tissue  are  pinched  up  preferably  on  the  outer 
side  of  the  arm  or  thigh  into  a  fold  about  one  quar- 
ter of  an  inch  broad.  The  needle  is  entered  in  front 
of  and  between  the  tips  of  the  left  thumb  and  index- 
finger  which  are  holding  the  fold,  avoiding  veins,  and 
pushed  obliquely  downward  until  the  sensation  is 
obtained  that  the  point  is  in  loose  tissue.  Slowly  in- 
ject the  fluid.  Withdraw  the  needle,  and  slightly 
rub  the  part,  to  diffuse  the  solution  into  a  greater 
area  of  the  areolar  tissue. 


CHAPTEE  III. 

manipulation  of  the  scalpel.— drainage.-- 
s  utures.—kno  ts. 

majs^ipulatiox  of  the  scalpel. 

1.  HoiD  to  liold  the  Scalpel, — Three  methods  of 
holding  the  scalpel  are  necessar}^  to  graceful  opera- 
tion: 

{a)  The  first  is  where  the  scalpel  is  held  as  a  pen. 
The  handle  of  the  instrument  passes  upward  to  the 
radial  side  of  the  index-finger.  The  lower  part  of 
the  handle  and  the  upper  part  of  the  blade  are  held 
between  the  pulp  of  the  thumb  on  one  side,  the  in- 
dex-finci:er  on  the  back,  and  the  middle  fins^er  over- 
lapping  the  other  side.  The  ring  and  middle  fingers 
are  semiflexed,  and  are  used  as  rests  to  steady  the 
hand. 

This  method  is  useful  in  the  limited  and  precise 
cuts  of  a  dissection. 

The  edge  of  the  scalpel  is  turned  forward  when 
used  to  cut  from  within  outward  after  puncturing, 
as  in  opening  an  abscess. 

{F)  The  second  method  is  where  the  scalpel  is 
held  like  the  boAV  of  the  violin.  The  direction  of 
the  instrument  is  almost  parallel  to  the  surface.  The 
handle  is  held  between  the  pulp  of  the  thumb  on. 


18  OPERATIVE  SURGERY  ON'  TEE  CADAVER. 

one  side  and  the  pnlj)s  of  all  the  other  fingers  on  the 
other.  The  pnlp  of  the  index-iinger  may  be  placed 
on  the  back  of  the  blade  if  firmness  is  required. 

This  method  allows  the  greatest  freedom  to  the 
hand,  hence  is  used  in  making  long  incisions. 

In  dividino;  tissue  over  the  director,  this  method 
is  used,  with  the  edge  turned  upward.  If  the  tissue 
is  divided  from  the  distal  to  the  proximal  end,  the 
handle  of  the  instrument  points  forward. 

((^')  In  the  third  method  the  scalpel  is  held  as  a 
table-knife.  The  handle  of  the  scalpel  is  kept  against 
the  palmar  surface  of  the  hand  by  the  ends  of  the 
middle  and  ring  fingers.  The  index-finger  bears 
upon  the  back  of  the  blade,  while  the  thumb  presses 
the  instrument  as^ainst  the  side  of  the  middle  fino^er. 

This  position  allows  a  great  deal  of  force  to  be 
exerted,  as  in  separating  muscular  attachments  from 
bones. 

2.  How  to  use  the  Scalpel ;  Incisions. — The  fore- 
going methods  of  holding  the  scalpel  should  be  prac- 
ticed while  making  incisions  into  the  abdominal  wall. 
Avoid  incising  the  median  line  of  the  abdomen,  in 
order  not  to  interfere  with  other  operations. 

Enter  the  point  of  the  scalpel  perpendicularly 
where  the  incision  is  to  begin,  through  the  integu- 
ment, stretched  equally  between  the  left  index-finger 
and  thumb.  Lower  the  handle  so  that  the  belly  of 
the  scalpel  will  be  applied  to  the  tissues.  Cut  the 
integument  without  much  pressure,  but  with  slight 
sawing  motion  to  the  desired  extent.  The  incision  is 
completed  as  it  was  begun,  with  the  scalpel  held  per- 
pendicularly to  avoid  "  tailing." 

Incisions  may  be  made  by  pinching  up  the  skin, 


MAmPULATION   OF  THE  SCALPEL.  19 

and  tlien  transfixing  and  cutting  outward,  or  by 
cutting  tlie  fold  from  the  surface  to  tlie  desired 
extent. 

In  making  tlie  incision  deeper,  make  the  cuts  of 
the  same  lengtli  as  the  first,  and  as  important  struct- 
ures are  approached  use  the  dii'ector.  With  a  pair 
of  thumb-forceps  pinch  up  very  superficially  the  tis- 
sue at  the  bottom  of  the  wound.  Nick  the  tissue  as 
close  to  the  ends  of  the  forceps  as  possible,  the  scal- 
pel being  held  short,  with  the  blade  flatwise  to  the 
surface,  and  making  a  right  angle  with  the  forceps. 
Enter  the  end  of  the  dii^ector  into  the  opening  formed, 
and  gradually,  with  slight  pressure  and  lateral  move- 
ments, introduce  it  to  the  angle  of  the  wound.  The 
end  of  the  director  should  be  inclined  slightly,  as  if 
to  push  through,  the  layer  of  tissue  being  raised 
during  its  introduction.  Place  the  point  of  the  knife 
into  the  groove,  and  incline  the  handle  toward  the 
director  as  much  as  j)ossible,  without  allowing  the 
point  to  escape  the  groove.  Advance  the  knife  held 
in  this  manner  with  a  slight  sawing  motion,  until  its 
point  is  arrested  in  the  cul-de-sac  at  the  end  of  the 
groove.  Raise  the  handle  of  the  knife  to  the  per- 
pendicular position  to  divide  completely  the  tissues 
up  to  the  angle  of  the  wound. 

This  procedure  is  repeated  in  order  to  divide  the 
tissues  to  the  other  angle  of  the  wound. 

Let  each  cut  advance  the  operation  systemati- 
cally. 

If  a  loose  layer  underlie  a  fascia,  as  is  the  case 
with  the  peritonaeum,  be  careful  that  a  fold  of  the 
underlying  tissue  does  not  override  the  point  of  the 
director. 


20  OPERATIVE  SURGERY  02^  THE  CADAVER. 

Tissues  overlying  the  director  should  be  exam- 
ined before  being  divided. 

The  overlying  tissues  may  be  divided  with  scis- 
sors, one  blade  being  kept  in  the  groove.  Hold  the 
scissors  vn\h  the  thumb  and  middle  fingers  in  the 
rino-s,  and  the  index-fino^er  on  the  blade  to  direct. 

DRAINAGE. 

To  illustrate  this  principle,  prepare  a  piece  of  rub- 
ber tubing  with  free  openings  cut  into  its  lumen  along 
its  sides  at  short  intervals.  Introduce,  if  necessary 
with  a  probe  or  thumb-forceps,  one  end  of  the  tubing 
down  to  the  bottom  of  the  wound.  This  end  must 
be  cut  slanting,  to  facilitate  its  introduction.  Bring 
the  other  end  out  of  the  most  dependent  part  of  the 
wound.  Fasten  a  safety-pin  through  the  tubing  as  it 
leaves  the  wound,  or  pierce  the  tubing  with  a  needle 
carrying  a  ligature,  which  is  to  be  tied  loosely  around 
the  member,  or  fastened  by  plaster  to  the  surface. 
Cut  the  tubing  flush  with  the  surface. 

Introduce  in  like  manner  a  piece  of  prepared  tub- 
ing into  the  superior  angle  of  the  wound  and  se- 
cure it. 

Strands  of  horse-hair,  long  enough  to  extend  be- 
yond the  angles  of  the  wound  while  lying  in  its 
deepest  part,  or,  when  doubled,  to  reach  from  the 
bottom  to  the  most  dependent  angle  of  the  wound, 
may  be  used  to  illustrate  correctly  the  principle  of 
drainage. 

Patulous  openings  can  be  made  by  removing  a 
column  of  tissue,  with  an  instrument  cutting  like  a 
leather- Y)unch,  from  the  deeper  parts  of  the  wound  to 
the  surface  in  dependent  positions  (canalization). 


SUTURES.  21 


SUTUKES. 


1.  The  continuous  or  glover"^ s  suture  is  made  by 
piercing  one  lip  of  the  wound  from  without  and  the 
other  correspondingly  from  within,  thus  bringing  the 
armed  needle  out,  so  that  the  points  of  entry  and 
exit  are  opposite  and  equidistant  from  the  margin. 

When  the  next  and  subsequent  stitches  are  to  b^ 
taken,  the  needle  is  entered  on  the  same  side  as  for 
the  first  stitch,  and  at  equal  distances  apart.  The 
ligature  extends  diagonally  across  the  line  of  the 
wound  from  one  point  of  exit  to  the  next  of  entry. 

Care  must  be  taken  to  pierce  the  integument  per* 
pendicularly. 

Use  a  curved  or  half -curved  needle,  if  the  stitches 
are  to  run  deep  through  the  tissues. 

The  left  hand  steadies  and  affords  counter-press- 
ure, enabling  the  needle  to  pierce  the  tissues. 

Accurate  apposition  of  thin-lipped  wounds  is  best 
attained  by  this  suture  where  there  is  little  force  re- 
quired to  maintain  coaptation. 

To  remove  this  suture,  cut  each  diagonal  turn  at 
its  entry  and  then  withdraw  by  means  of  forceps, 
holding  the  left  index-finger  applied  closely  to  the 
point  of  exit  to  prevent  the  lip  of  the  wound  from 
bearing  any  strain. 

When  these  sutures  are  used  to  bring  together 
the  deeper  parts  of  a  wound,  they  are  called  hurled 
sutures. 

2.  The  interrufpted  suture  is  made  like  the  con- 
tinuous, except  that  it  does  not  run  from  one  exit  to 
the  next  entry  of  the  suture,  but  is  cut  after  each 
complete  passage  of   the  needle,  and  the  two  ends 


22  OPERATIVE  SURGERY  ON  THE  CADAVER. 

are  united  by  a  knot.  The  knots  should  fall  on  one 
side  of  the  wound,  either  the  side  of  the  entries  or 
that  of  the  exits  of  the  sutures. 

To  remove  the  suture,  cut  the  ligature  at  its  point 
of  entry  if  the  knot  is  over  the  exit,  and  then  by 
means  of  forceps  draw  upon  the  knot,  the  left  index- 
finger  being  applied  near  the  exit  to  prevent  drag- 
ging on  the  lip  of  the  wound. 

3.  The  quilled  suture  is  made  by  passing  a  stout 
needle,  fitted  into  a  handle,  through  the  tissues  from 
one  side  to  the  corresponding  point  of  the  other  side 
of  the  wound.  Thread  the  eye  which  is  near  the 
point  with  a  double  ligature,  and  withdraw  the 
needle,  thus  carrying  one  end  of  the  double  ligature 
through  to  the  other  side  of  the  wound.  A  curved 
needle  is  best  adapted  for  making  this  suture. 
Through  the  loop  of  the  double  ligature  pass  a  piece 
of  catheter,  and  secure  it  by  drawing  on  the  double 
lio:ature  from  the  other  side  of  the  wound.  Tie  the 
two  free  ends  of  the  double  ligature  over  a  similar 
piece  of  catheter. 

If  a  number  of  sutures  are  used,  run  a  piece  of 
bougie  through  all  the  loops,  which  will,  of  course, 
run  parallel  to  the  y/ound,  and  secure  a  similar  piece 
of  bougie  on  the  other  side  between  the  ends  of  the 
double  ligatures. 

This  suture  holds  the  deeper  parts  in  apposition ; 
hence,  the  pieces  of  bougie  must  be  removed  about 
an  inch  from  the  margin  of  the  wound,  to  make  the 
course  of  the  ligatures  as  nearly  straight  as  possible. 

The  continuous  or  interrupted  suture  is  used,  in 
conjunction  with  the  quilled  suture,  to  secure  apposi- 
tion of  the  superficial  parts  of  the  wound. 


8UTUEES.  23 

If  buttons  are  used  instead  of  quills,  tlie  suture  is 
called  the  button-suture. 

4.  The  twisted  suture  is  made  by  passing  metal 
pins  tlirougli  the  lips  of  the  wound.  The  pins  should 
cross  the  wound  as  deep  as  possible,  and,  if  the  tissue 
is  completely  divided  into  flaps,  they  should  pierce 
almost  to  the  other  surface.  Enter  the  pins  some 
distance  from  the  margin,  and  bring  them  out  at  cor- 
responding points  on  the  other  side  of  the  wound. 
The  pins  being  placed,  wrap  around  them  cotton 
yarn,  in  a  figure  of  eight,  making  the  crossings  of  the 
yarn  correspond  to  the  line  of  incision.  As  each  pin 
is  sufficiently  wrapped,  the  yarn  is  continued  diago- 
nally from  the  lower  turn  of  that  pin  to  the  upper  of 
the  next.  Clip  the  points  of  the  pins,  and  protect 
the  skin  by  placing  beneath  the  ends  small  pieces 
of  adhesive  plaster. 

This  suture  keeps  the  whole  surface  of  a  wound 
in  apposition,  and  from  being  used  in  hare-lip  is  called 
hare-lip  suture. 

The  pins  should  be  pointed,  or  a  pin-carrier  will 
be  necessary  (Buck,  Post)  to  guide  them  into  posi- 
tion. 

5.  The  quilt  or  fold  suture  is  made  by  passing 
the, needle  through  the  lips  of  the  wound  at  equidis-. 
tant  and  opposite  points.  A  knot  is  now  made,  which 
must  lie  over  the  point  of  exit.  Now  enter  the 
needle  on  the  side  through  which  the  needle  has  just 
made  its  exit,  and  bring  it  out  at  a  point  exactly  op- 
posite and  equidistant  from  the  margin  of  the  wound. 
In  this  suture  the  loops  lie  parallel  to  the  wound. 

Secure  the  last  stitch,  as  in  the  case  of  the  glover's 
suture,  by  tying  together  the  free  end  of  the  loop 


24  OPERATIVE  SURGERY  ON  THE  CADAVER. 

wMcli  liolds  tlie  needle,  and  the  double  end  made  by 
cuttino^  the  needle  loose  from  the  lio-ature.  Before 
making  the  last  stitch,  pull  several  inches  more  of 
the  ligature  through  the  eye  of  the  needle,  so  that 
the  free  end  will  not  be  carried  through  the  punct- 
ure when  the  needle  makes  it  exit. 

The  quilled  or  button,  the  twisted,  and  the  quilt 
sutures,  are  sutures  of  relaxation,  and  require  the 
glover's  or  interrupted  suture  to  be  used  in  conjunc- 
tion to  appose  the  more  superficial  parts  of  the 
wound. 

If  mre  is  used  as  a  suture,  the  ends  are  twisted 
together,  and  the  twisted  portion  of  the  suture  is 
placed  as  the  knot  of  the  silk  ligature,  away  from 
the  line  of  incision.  Make  the  wire  lie  flat  across  the 
wound  by  bending  it  to  make  an  angle  at  the  entry 
and  exit.  The  ends  may  be  clipped  to  one  quarter 
of  an  inch,  or  all  run  into  a  piece  of  rubber  tubing. 

The  suture  must  be  cut  near  the  twist  when  it  is 
to  be  removed.  Straighten  as  much  as  possible  the 
wire  and  run  it  into  the  slit  of  an  applicator.  Press 
the  applicator  firmly  enough  to  prevent  any  force 
being  exerted  on  the  flap,  while  the  twist  of  the  su- 
ture is  caught  in  the  forceps  and  steadily  drawn  upon. 

Always  aim  at  having  no  more  strain  on  sutures 
than  is  required  to  establish  perfect  coaptation  with- 
out any  wrinkling  of  the  lips  of  the  wound. 

6.  The  special  sutures  for  organs  covered  by  se- 
rous membrane  will  be  practiced  in  connection  with 
the  operations  performed  upon  the  intestine.  The 
needles  should  have  rounded  edges. 

(a)  Lemherfs  Suture. — Enter  the  needle  about  one 
third  of  an  inch  from  the  cut  edge  and  pierce  a  fold  of 


SUTURES.  25 

peritonaeum.  This  fold  should  include  nearly  a  quar- 
ter of  an  incli  of  the  peritonaeum  between  the  point  of 
entrance  of  the  needle  and  the  cut  edge.  Enter  the 
needle  near  the  other  edge,  and  pierce  a  similar  fold 
of  peritonaeum  exactly  opposite.  Invert  the  edges  of 
the  wound,  and  either  make  the  suture  continuous  or 
interrupted. 

This  suture  brings  into  contact  narrow  surfaces 
perpendicular  to  the  cut  margin. 

(h)  Geltfs  Suture,^ — Enter  the  needle  about  a 
quarter  of  an  inch  from  the  margin  and  advance  it 
parallel  to  the  wound,  piercing  a  fold  of  peritonaeum. 
The  entrance  and  exit  of  the  needle  should  be  sep- 
arated about  a  quarter  of  an  inch.  Enter  the  needle 
on  the  other  side,  at  a  point  corresponding  to  the  exit, 
and  pierce  a  similar  fold  of  peritonaeum,  bringing  the 
needle  out  at  a  point  opposite  and  corresponding  to 
the  first  entrance  of  the  needle.  The  beginning  and 
ending  of  the  suture  are  thus  opposite  each  other 
across  the  wound,  and  are  to  be  secured  by  a  knot 
after  the  eds^es  of  the  wound  have  been  inverted. 

A  continuous  Gely's  suture  may  be  made  by 
threading  a  needle  on  each  end  of  a  ligature  and 
then  entering  the  needles  on  opposite  sides  of  the 
wound  at  corresponding  points.  Take  up  similar 
folds  of  peritonaeum  by  advancing  the  needles  par- 
allel to  the  edges  of  the  wound.  The  two  needles 
may  now  change  sides,  or,  better,  the  ends  may  be 
tied  and  the  suture  made  secure.  The  needles  must 
enter  at  the  points  of  exit  of  the  last  suture,  and 
similar  folds  of  peritonaeum  be  pierced  as  before. 

*  These  sutures,  if  made  to  pierce  into  tlie  lumen  of  the  gut,  are  ob- 
jectionable. 


26  OPERATIVE  SURGERY  OR  THE  CADAVER. 

This  suture  secures  tlie  contact  of  a  surface  of 
peritonaeum  extending  parallel  to  tlie  wound. 

(c)  Joberfs  Suture. — Strip  tlie  mesentery  two 
thirds  of  an  inch  back  from  the  ends  of  a  divided 
gut.  Insinuate  into  the  lumen  of  the  upper  gut  one 
end  of  a  piece  of  tallow-candle,  and  into  that  of  the 
lower  the  other  end  of  the  candle.  Pierce  the  upper 
end  of  gut  from  without  inward,  about  a  quarter  of 
an  inch  from  the  margin  through  the  surface  from 
which  the  mesentery  was  stripped.  Invaginate  one 
half  inch  of  the  cut  end  of  the  lower  gut  into  its  own 
lumen.  Pierce  the  invaginated  gut  near  its  cut  mar- 
gin, and  the  invaginating  gut  lying  over  it,  from 
within  outward  through  the  surface  from  which  the 
mesentery  was  stripped. 

Similar  sutures  are  to  be  passed  all  around  the 
whole  circumference  of  the  divided  ends  of  the  intes- 
tine. The  upper  ends  of  the  ligatures  are  now  passed 
through  the  lower  gut  near  the  folded  margin.  The 
candle  is  slipped  down  the  alimentary  canal,  and  the 
ends  of  the  ligature  are  secured. 

Serous  surfaces  are  brought  into  contact  except 
where  the  mesentery  was  attached,  where  raw  sur- 
faces are  apposed. 

The  divided  upper  gut  is  invaginated  into  the  in- 
vaginated portion  of  the  lower  divided  gut,  imitating 
intussusception. 

(d)  Double  Continuous. — This  is  the  ordinary  con- 
tinuous suture  carried  around  the  circumference,  and 
then  continued  back  in  the  middle  of  the  spaces  left 
between  the  former  entrances  and  exits  of  the  ligature. 

The  edges  are  inverted  to  bring  together  serous 
surfaces. 


KNOTS.  27 

(e)  Czernys  suture  may  be  used  in  connection  witli 
most  of  the  f  oreo^oins:  sutures  with  advantas;e.  Enter 
the  needle  through  the  peritoneal  surface  near  the 
margin  of  the  wound,  and  bring  it  out  through  the 
wound-surface  near  the  edge  of  the  mucous  mem- 
brane. Pierce  the  opposite  wound-surface  near  the 
mucous  edge,  and  bring  the  needle  out  through  the 
peritoneal  surface  near  the  margin  of  the  wound. 
Invert  the  peritoneal  edge  of  the  wound  and  secure 
the  ends  of  the  ligature  by  means  of  a  knot. 

These  stitches  are  to  be  made  one  eighth  of  an 
inch  apart. 

KNOTS. 

1.  'Reef-Knot. — The  reef-knot  is  a  double  knot. 
The  first  knot  is  made  by  making  a  loop  and  carrying 
the  end  of  the  ligature  held  in  the  right  hand  for- 
ward over  the  end  held  in  the  left  hand,  so  as  to  be 
turned  through  the  loop  backward.  The  second 
knot  is  made  (the  ends  of  the  ligature  having  changed 
hands)  by  carrying  the  end  held  in  the  right  hand 
backward  over  that  held  in  the  left  hand,  so  as  to  be 
passed  through  the  loop  forward. 

The  second  turn  of  the  knot  should  not  be  drawn 
upon  with  great  force. 

2.  Surgeon's  Knot. — This  is  a  double  knot  having 
the  end  of  the  ligature  turned  through  the  first  loop 
twice.  The  second  knot  is  made  by  turning  the  end 
of  the  ligature  in  the  same  manner  once  through  the 
second  loop. 

The  first  knot,  having  two  turns,  is  not  liable  to 
slip. 


CHAPTEE  IV. 

OPERATIONS   ON  THE  HEAD  AND  NECK. 

TKEPHIISriNG. 

Crown  Trephine,  Golfs  Trephine* 

Shave  tlie  part.  Make  semilunar,  crucial,  or  ;^- 
shaped  incisions  down  to  the  bone,  and  raise  all  the 
tissues  in  flaps  with  a  periosteum  elevator.  Make 
the  flaps  sufllciently  large  to  expose  a  surface  of  bone 
which  will  allow  the  crown  of  the  trephine  to  be 
applied.  Hold  the  flaps  from  the  wound  by  tenac- 
ula,  or  by  ligatures  passed  through  them  near  their 
edges.  Project  the  central  pin  of  the  trephine 
slightly  beyond  the  crown,  and  make  it  fast.  Hold 
the  handle  of  the  trephine  between  the  palm  of  the 
hand  and  the  middle,  ring,  and  little  Angers,  and  ap- 
ply the  thumb  and  index-finger  along  the  shaft. 

The  operator  must  work  from  a  higher  level  than 
the  part  to  be  trephined,  in  order  to  bear  upon  the 
instrument. 

Place  the  central  pin  of  the  trephine  in  the  cen- 
ter of  the  surface,  and  with  a  few  turns  of  the  han- 
dle from  left  to  right  and  right  to  left,  and  with 
slight  pressure,  make  it  bore  into  the  bone.  After  a 
few  more  turns,  the  instrument  being  held  perpen- 

*  See  chapter  x,  use  of  saw. 


OPERATIONS  ON'  THE  HEAD   ANTD  NECK.  29 

dicularly  to  the  surface,  tlie  teetli  of  the  crown  will 
make  a  circular  track.  When  this  groove  is  of  suffi- 
cient depth  to  keep  the  instrument  from  slipping,  the 
central  pin  is  retired  and  made  fast  before  advancing 
farther.  JS^ow  begin  again  to  saw,  removing  the  tre- 
phine often  to  clean  its  teeth  with  a  brush,  and  to  as- 
certain the  depth  of  the  groove  by  means  of  a  probe 
or  a  quill  toothpick. 

The  color  of  the  dust  will  change  from  white  to 
a  reddish  color  when  the  cancellous  tissue  is  reached. 

When  the  instrument  is  well  advanced  in  the 
bone,  screw  into  the  small,  central  hole,  made  by  the 
pin  in  the  first  part  of  the  operation,  one  of  Heine's 
tirefonds  (a  small  screw  with  an  eye  in  its  head). 
The  screw  must  not  be  longer  than  the  circular 
groove  is  deep. 

Continue  to  advance  with  the  trephine  until  the 
toothpick  discloses  the  complete  section  of  the  bone 
in  a  part  of  the  groove.  The  trephine  must  be 
slightly  slanted  and  made  to  saw  only  on  the  undi- 
vided part. 

A  Gait's  trephine  is  in  the  shape  of  a  truncated 
cone,  and  becomes  w^edged  as  soon  as  the  bone  is 
completely  severed,  hence  is  a  safe  instrument. 

Examine  frequently  to  find  if  the  section  is  com- 
plete. When  the  section  is  completed,  fasten  a  hook 
(Roser)  into  the  eye  of  the  tirefond,  and  pull  gently 
on  the  disk,  aiding  in  its  removal  with  the  elevator. 

Make  the  sawn  edge  perfectly  smooth. 

If  two  walls  of  bone  are  to  be  sawn  through,  the 
first  must  be  sawn  wdth  a  large  trephine,  and  the  sec- 
ond with  a  much  smaller  one,  as  when  trephining  the 
frontal  sinuses. 


30  OPEEATIVE  SURGERY  ON  THE  CADAVER. 

In  trephimng  the  long  bones,  as,  for  example,  tlie 
head  of  the  tibia,  the  small  crown  trephine  is  used. 

To  study  trephining  for  depressed  fracture  of  the 
skull,  fracture  with  a  hammer  the  skull  in  various 
localities.  Expose  the  parts  as  directed.  Place  the 
point  of  the  pin  of  the  trephine  near  the  margin  on 
the  solid,  undepressed  bone,  and,  if  possible,  away 
from  sinuses,  or  the  middle  meningeal  artery. 

Select  a  spot  where  the  line  of  fracture  between 
two  dejDressed  fragments  meets  the  margin.  The 
crown  of  the  trephine  must  overlap  the  margin  of  the 
depression.  Remove  the  disk  or  portion  of  a  disk  of 
bone,  which  will  allow  the  elevator  to  raise  the  de- 
pressed fragments.  Remove  all  detached  fragments 
and  small  fragments  which  have  been  considerably 
depressed.  Make  the  bony  margin  smooth  with  the 
rongeur,  gouges,  chisels,  or  scoops.  Saw  any  sharp 
angles  of  bone  with  Hey's  saw,  using  the  straight 
toothed  edge  for  straight  section,  and  the  rounded 
edge  for  curved  section. 

If  the  wound  is  made  with  a  pick,  the  fragments 
removed  must  be  fitted  together  to  ascertain  if  any 
pieces  have  been  driven  into  the  brain. 

Provide  for  drainage  from  the  wound,  and  stitch 
together  the  flaps. 

OPEEATIOIS"    FOR    STRABISMUS. 

Place  the  subject  on  the  back.  Stand  facing  the 
subject.  Keep  the  eyelids  separated  by  means  of  a 
stop-speculum. 

Catch  up  the  coDJunctiva  just  external  to  the  cor- 
nea with  toothed  forceps,  and  rotate  the  eye  outward. 
An  assistant,  standing  behind  the  head  of  the  sub-' 


OPERATIONS  ON  THE  HEAD  AND  NECK.  31 

ject,  must  hold  these  forceps.  This  places  the  eye 
in  position  for  operation  upon  the  tendon  of  the  in- 
ternal rectus. 

To  operate  upon  the  tendon  of  the  external  rectus, 
the  conjunctiva  is  seized  internally  to  the  cornea  and 
the  globe  rotated  inward. 

Pinch  up  with  a  pair  of  ordinary  dissecting  for- 
ceps a  vertical  fold  of  conjunctiva  and  sub-conjunc- 
tival  tissue,  at  the  point  of  intersection  of  the  lower 
horizontal  and  the  vertical  tangents  to  the  cornea. 
With  a  small  pair  of  blunt-23ointed  scissors,  snip  this 
fold,  cutting  it  do^vQ  to  its  base,  thus  making  a  hori- 
zontal wound.  This  cut  divides  the  capsule  of  Tenon, 
thus  -opening  into  the  lymph-space  around  the  scle- 
rotic. 

Still  holding  the  forceps  in  the  left  hand,  insert  a 
strabismus-hook  into  the  opening.  Direct  the  end  of 
the  hook  downward  slightly,  and  then  horizontally 
backward,  half  the  distance  on  the  globe  toward  the 
entrance  of  the  optic  nerve.  Bring  the  hook  upward 
and  forward  until  its  end  bulges  the  conjunctiva  just 
above  the  upper  edge  of  the  tendon. 

In  these  manoeuvres,  the  end  of  the  instrument 
must  be  kept  applied  to  the  surface  of  the  sclerotic. 

Pull  slightly  upon  the  tendon  toward  the  cornea. 
The  hook  is  retained  posterior  to  the  corneal  mar- 
gin by  the  tendon.  With  the  small,  probe-pointed 
scissors  curved  on  the  flat,  divide  the  tendon  from 
below  upward  between  the  hook  and  the  cornea. 
The  lower  blade  of  the  scissors  must  be  kept  in  con- 
tact with  the  hook,  and  the  upper  between  the  ten- 
don and  the  conjunctiva.  The  curve  of  the  scissors 
must  follow  the  curve  of  the  hook. 


32  OPERATIVE  SURGERY  OJ}f  THE  CADAVER. 

Searcli  to  find  if  any  part  of  tlie  tendon  is  undi- 
vided, wliicli  bands  would  prevent  the  liook  from 
advancing  to  tlie  corneal  margin. 

EXCISIONS"    OF   THE   EYE. 

Keep  tlie  eyelids  apart  by  means  of  a  sto]3-specu- 
lum. 

With  a  pair  of  toothed  forceps  catch  hold  of  the 
conjunctiva  and  sub-conjunctival  tissue  external  to 
the  cornea.  Divide  these  tissues  all  around  the  cor- 
nea, keeping  close  to  the  corneal  margin.  Draw  up 
with  a  strabismus-hook  the  tendon  of  the  external 
rectus,  which  is  to  be  divided  about  an  eighth  of  an 
inch  from  its  attachment  to  the  sclerotic.  Grasp 
with  forceps  the  stump  of  tendon  of  the  external  rec- 
tus left  attached  to  the  sclerotic  in  order  to  control 
the  globe  in  the  subsequent  steps  of  the  operation. 

Hook  up  the  tendons  of  the  superior  and  inferior 
recti  muscles,  and  divide  them  close  to  the  sclerotic. 

Pass  posteriorly  a  pair  of  probe-pointed  scissors 
curved  on  the  fiat  with  their  curve  following  the  ex- 
ternal surface  of  the  globe  until  their  point  touches 
the  optic  nerve.  Separate  the  blades  of  the  scissors 
and  include  the  nerve,  which  must  then  be  divided. 

The  globe  is  now  easily  drawn  forward,  when  the 
attachment  of  the  oblique  and  internal  rectus  muscles 
and  any  fibrous  bands  must  be  divided  close  to  the 
sclerotic. 

EXTRACTIOIS^    OF    TEETH. 

Place  the  subject  on  the  back,  with  a  block  under 
the  head  during  the  extraction  of  the  lower  teeth. 

The  head  must  hang  over  a  block  during  the  ex- 
traction of  the  upper  teeth. 


OPERATION'S  ON  THE  HEAD  AND  NECK.  33 

Grasp  the  forceps  in  tlie  right  hand,  with  the 
thumb  laid  along  one  bar  somewhat  between  the  two 
bars  of  the  handle,  to  prevent  a  crushing  force  being 
exerted  on  the  tooth. 

Stand  on  the  right-hand  side  of  the  table. 

Lightly  apply  suitable  forceps  to  the  neck  of  the 
tooth.  Push  the  sharp  edges  of  the  blades  of  the 
forceps  between  the  gum  and  the  tooth,  until  arrested 
by  the  alveolar  process  of  the  maxilla.  Tighten  the 
grasp  on  the  tooth  when  the  diif erent  motions  for  the 
different  extractions  are  begun. 

Upper  Incisors  and  Canine. — To  extract  these, 
use  straight  forceps  with  blades  having  one  groove. 
These  teeth  have  conical  roots,  hence  are  loosed  by 
slight  rotation.  The  blades  of  the  forceps  are 
crowded  down  into  the  socket  so  as  to  catch  hold 
nearer  the  root.  To  extract,  pull  downward  and 
slightly  forward,  after  the  tooth  has  been  loosened 
sufficiently  by  slight  rotation. 

Upper  Bicnspids,  —  Use  forceps  with  narrow 
blades,  and  with  the  handle  curved  to  avoid  coming 
in  contact  with  the  lower  teeth.  The  tooth  has  a 
root  which  is  flattened  laterally.  Apply  the  f  orcejDS ; 
force  the  tooth  outward  and  then  tilt  it  outward  and 
inward  until  loose.  Crowd  the  forceps-blades  toward 
the  root,  and  extract  by  pulling  downward. 

Upper  Molars, — Right  and  left  forceps  are  neces- 
sary. The  outer  blade  has  two  grooves  corresponding 
to  the  roots  of  the  tooth.  The  blades  make  an  ob- 
tuse angle  with  the  handle.  The  internal  edge  of 
the  alveolar  process  being  the  stronger  and  the  pala- 
tine root  liable  to  fracture,  apply  the  forceps  and 
force  the  tooth  outward.     Move  the  tooth  from  side 


34  OPERATIVE  SUEGERY  0^  THE  CADAVER. 

to  side,  pusii  the  blades  of  the  forceps  deeper  into  the 
socket,  and  extract  by  pulling  downward, 

Lower  Incisors. — The  tooth  has  a  root  flattened 
laterally.  A^Dply  the  forceps;  X3ull  outward,  and 
then,  by  rocking  the  tooth  inward  and  outward, 
loosen  it  sufficiently  to  allow  the  blades  of  the  for- 
ceps to  be  forced  deeper  toward  its  root.  Extract 
by  drawing  upward  and  slightly  outward. 

Lower  Canine. — The  root  is  conical,  hence  the 
tooth  is  removed  'in  the  same  manner  as  the  upper 
canine,  except  that  the  pull  is  upward. 

Lower  Bicuspids.  —  Use  forceps  with  narrow 
blades,  which  form  almost  a  right  angle  with  the 
handle.  These  teeth  are  extracted  like  the  upper  bi- 
cuspids, except  that  they  are  pulled  upward. 

Lower  Molars. — The  roots  are  one  internal  and 
one  external.  Apply  the  forceps  and  force  the  tooth 
outward.  Rock  the  tooth  forward  and  backward, 
because  the  roots  incline  backward.  Push  the  blades 
of  the  forceps  deeper  toward  the  roots,  and  extract 
by  drawing  upward.  Protect  the  roof  of  the  mouth 
by  holding  the  forceps  near  the  blades. 

Extract  broken  roots  of  teeth  by  an  elevator, 
having  a  short,  thin  blade,  which  is  grooved  on  the 
inner  side.  The  blade  has  a  sharp-pointed  or  broad 
edge,  and  bends  so  as  to  make  an  obtuse  angle  with 
the  shaft.  Two  are  necessary,  right  and  left.  In 
extracting  the  root,  make  the  internal  plate  of  the 
alveolar  process  the  fulcrum  for  the  elevator. 

PEEFORATION    OF   THE    ANTRUM. 

Place  the  subject  on  the  back,  with  the  head  hang- 
ing over  a  block.     Stand  on  the  right-hand  side  of 


OPERATIONS  OK  THE  BEAD  AND  NECK.  35 

the  table.  Extract  the  first  or  second  molar  tooth  of 
the  upper  jaw,  the  rule  being  to  choose  the  one  most 
decayed. 

Hold  the  bone-drill,  or,  as  Fergusson  recommends, 
an  ordinary  gimlet  in  the  right  hand,  with  the  index- 
finger  applied  along  the  shaft.  Enter  the  instru- 
ment into  the  socket  of  the  tooth,  extracted,  and  by 
boring  upward  and  slightly  inward,  keeping  up  uni- 
form pressure,  perforate  the  floor  of  the  antrum. 

The  index-finger,  applied  along  the  shaft,  prevents 
the  instrument  from  plunging  through  the  cavity  of 
the  antrum  against  the  floor  of  the  orbit. 

The  antrum  may  be  perforated  from  the  canine 
fossa  by  dissecting  oif  the  tissues,  the  upper  lip  being 
turned  upward,  until  the  bone  is  cleared,  and  then 
by  using  a  trephine  or  drill  to  bore  horizontally 
backward. 

EXCISIOIS"    OF    THE    TOIS^GUE. 

Partial  Excision,  —  The  only  partial  excision 
which  claims  notice  is  that  of  a  longitudinal  half 
of  the  oro:an. 

The  lingual  artery  of  the  corresponding  side  must 
be  ligated  in  the  triangle  formed  by  the  hypoglossal 
nerve  and  the  tendon  of  the  digastric  muscle,  as  a 
step  of  the  operation  (see  ligation  of  Unguals). 

Eetain  the  jaws  widely  separated  by  means  of  a 
mouth-gag.  Pass  two  stout  ligatures  through  the 
front  half  of  the  tongue,  one  on  each  side  of  the  me- 
dian line.  Pull  the  tongue  forward  and  upward. 
Cut  with  a  scalpel  the  mucous  membrane  in  the  me- 
dian line  of  the  under  surface  of  the  tongue  from  the 
tip  to  the  frsenum.  Divide  with  the  scissors  the  frse- 
num,  also  the  mucous  membrane  reflected  from  the 


36  OPERATIVE  SURGERY  0^  THE  CADAVER. 

under  surface  of  tlie  half  of  tlie  organ  to  be  removed 
to  the  floor  of  the  mouth.  Divide  the  mucous  mem- 
brane reflected  from  this  side  to  the  fauces,  also  the 
underlying  muscles.  Pull  the  tongue  forward  and 
downward,  and  cut  with  a  scalpel  the  mucous  mem- 
brane, and  slightly  the  underlying  muscular  tissue 
along  the  dorsum  in  the  median  line  from  the  root  to 
the  tip. 

With  the  fingers  separate  the  two  halves  of  the 
tongue  all  the  way  to  the  hyoid  bone.  Tear  with  the 
fingers  the  attachments  to  the  under  and  lateral  sur- 
faces. 

Sever  the  part  from  the  hyoid  bone  by  means  of 
scissors,  blunt-pointed,  and  curved  on  the  flat. 

By  traction  on  the  ligature  through  the  remaining 
half  of  the  organ,  the  cut  surface  is  brought  into 
view. 

Complete  Excision. — Ligate  the  lingual  arteries 
and  perform  tracheotomy  as  steps  of  the  operation 
(see  tracheotomy  and  ligation  of  Unguals). 

Keep  the  jaws  separated  by  means  of  a  gag.  Pass 
a  stout  ligature  through  the  anterior  part  of  the  tongue 
and  draw,  by  pulling  on  the  ligature,  the  tongue  up- 
ward and  forward. 

Cut  the  mucous  membrane  on  the  inner  surface  of 
the  symphysis  menti,  and  separate  the  tissues  from 
the  bone  with  an  elevator,  until  the  origins  of  the 
muscles  attached  to  the  genial  tubercles  are  exposed. 
Cut  these  tendons  close  to  the  bone. 

Draw  the  tongue  forward,  and  pass  a  ligature 
through  each  lateral  glosso-epiglottidean  ligament. 
Bring  these  ligatures  out  of  the  angles  of  the  mouth 
and  fasten  them  to  the  cheeks  by  plaster. 


OPERATION'S  ON  THE  HEAD  AND  NECK.  37 

Divide  witli  scissors  the  frsenum  and  tlie  mncons 
membrane  at  its  reflection  from  the  under  surface  of 
the  tongue  to  the  floor  of  the  mouth,  also  the  mucous 
membrane  and  muscular  attachments  to  the  sides  of 
the  organ.  Tear  with  the  fingers  all  tissues  neces- 
sary to  free  the  tongue  to  its  base. 

Slip  the  noose  of  an  ecraseur  over  the  tongue 
down  to  its  attachment  to  the  hyoid  bone.  Prevent 
the  ecraseur  from  slipping  forward  by  passing  hare- 
lip pins  through  the  tongue  in  front  of  the  noose. 
Begin  slowly  to  divide  the  tissues  in  the  loop  of  the 
ecraseur,  by  making  about  two  turns  of  the  handle 
every  minute. 

By  drawing  on  the  ligatures  passed  through  each 
lateral  gloss o-epiglottidean  fold  the  stump  attached 
to  the  hyoid  bone  may  be  inspected. 

If  removal  beneath  the  inferior  maxilla  is  prac- 
ticed, Kocher's  method  is  recommended  (see  text- 
books on  surgery). 

BEOXCHOTOMY. 

Thyrotomy,  Laryngotomy^  Tracheotomy. 

Place  the  subject  on  the  back  with  the  shoulders 
depressed.  Place  a  block  under  the  neck  and  allow 
the  head  to  hang  backward.  Stand  on  the  right-hand 
side  facing  the  subject. 

1.  Thyrotorny. — Steady  the  thyroid  cartilage  be- 
tween the  index-finger  and  thumb  of  the  left  hand. 
Make  an  incision  in  the  median  line  from  the  hyoid 
bone  to  the  cricoid  cartilao-e  throuo^h  the  skin  and 
fasciae.  Divide  the  fibrous  connection  between  the 
sterno-hyoid  muscles.  Separate  the  sides  of  the 
wound  by  means  of  retractors.  Ligate,  if  present, 
the  communicating  branch  between  the   two  hyoid 


38  OPERATIVE  SURGERY  ON  THE  CADAVER. 

arteries  just  below  tlie  liyoid  bone,  also  that  of  the 
crico-thyroid  arteries  below  the  thyroid  cartilage. 

Locate  with  the  left  index-finger  the  notch  on  the 
superior  border  of  the  thyroid  cartilage  which  marks 
the  junction  of  its  halves.  Divide  the  thyroid  carti- 
lage from  this  notch  downward,  never  deviating  from 
the  median  line.  Open  into  the  larynx  through  the 
mucous  membrane  exactly  in  the  median  line,  to 
avoid  woundino^  the  vocal  cords.  Eetract  the  alae  of 
the  cartilage. 

In  closing  the  wound  the  halves  of  the  cartilage 
must  be  accurately  joined  by  sutures.  Provide  for 
drainage,  and  stitch  the  integument  and  fascia  to- 
gether. 

2.  Laryngotomy, — Locate  the  cricoid  cartilage. 
The  space  just  above  this  cartilage  and  below  the  thy- 
roid in  the  median  line  is  the  site  of  the  operation. 

Make  an  incision  in  the  median  line  extending 
three  quarters  of  an  inch  above  and  below  the  center 
of  the  crico-thyroid  space.  Divide  the  integument 
and  fascise  covering  the  crico  -  thyroid  membrane. 
Retract  the  sides  of  the  incision.  Steady  the  part  by 
means  of  a  tenaculum  hooked  under  the  lower  border 
of  the  thyroid  cartilage.  Pierce  the  membrane  above 
the  middle  of  the  cricoid  cartilage  and  enlarge  the 
opening  into  the  air  -  passage  by  lateral  incisions 
through  the  membrane  just  above  the  cricoid  car- 
tilage. 

Dilate  the  opening  and  insert  a  laryngeal  tube, 
directing  its  end  horizontally  backward  into  the  air- 
passage  and  then  downward.  If  the  opening  does 
not  readily  admit  the  tube,  divide  the  cricoid  carti- 
lage in  the  median  line. 


OPERATIONS  dlT  TEE  READ  AND  NECK.  39 

The  operation  may  be  performed  by  steadying 
the  part,  and  then  piercing  with  a  knife,  held  with 
the  middle  finger  applied  to  the  blade  one  half  inch 
from  the  point  as  a  guard,  all  the  tissues  into  the 
larynx.  This  puncture  must  be  made  a  little  below 
the  thyroid  cartilage  in  the  median  line,  the  blade  of 
the  knife  being  held  crosswise.  Turn  the  edge  of 
the  knife  and  cut  downward,  following  the  median 
line  to  or  through  the  cricoid  cartilage. 

In  the  child  the  incision  must  be  prolonged  in  the 
same  line  downward  through  two  or  three  rings  of 
the  trachea  (laryngo-tracheotomy). 

The  communicating  branch  between  the  crico-thy- 
roid  arteries  may  be  divided  below  the  thyroid  car- 
tilage. The  superior  thyroid  veins  communicate 
above  the  isthmus  of  the  gland,  and  hence  have  their 
communicating  branches  divided  in  laryngo-trache- 
otomy. 

Insert  the  tube  and  secure  it  in  position  by  means 
of  a  tape  encircling  the  neck.  Stitch  the  upper  and 
lower  ano^les  of  the  wound. 

3.  Traclieotomy. — Locate  the  cricoid  cartilage  with 
the  left  index-Hnger.  Make  an  incision  extending 
from  above  the  cricoid  cartilage  downward  two  inches 
in  the  median  line.  Divide  the  integument  and  fas- 
ciae and  separate  the  sterno-hyoid  muscles.  Ketract 
the  sides  of  the  wound.  Cut  the  fascia  transversely 
on  the  cricoid  cartilage  and  strip  it  downward  with 
the  isthmus  of  the  thyroid  gland,  (Bose).  Hook  the 
trachea  below  the  cricoid  cartilage  with  a  tenaculum 
and  draw  it  upward  and  forward. 

Pierce  the  trachea  with  a  scalpel  held  mth  its 
cutting  edge  upward  in  the  lower  angle  of  the  wound, 


40  OPERATIVE  SURGERY  OR  TEE  CADAVER. 

and  divide  it  upward  in  tlie  median  line  to  the  ex- 
tent of  three  quarters  of  an  inch. 

Dilate  the  opening  and  insert  a  tracheotomy -tube 
with  its  convexity  turned  upward.  Secure  the  tube 
by  means  of  a  tape,  and  stitch  the  angles  of  the 
wound. 

In  the  child  the  incision  reaches  nearly  to  the  up- 
per border  of  the  sternum.  The  trachea  being  small, 
avoid  w^ounding  its  posterior  wall. 

If  the  isthmus  of  the  thyroid  gland  can  not  read- 
ily be  displaced  downward,  catch  it  with  serrefines  on 
each  side  and  divide  it  in  the  median  line. 

Tlie  communicating  branches  between  the  superior 
thyroid  veins  are  divided  as  they  cross  the  median 
line  above  the  isthmus  of  the  thyroid  gland. 

It  is  seldom  necessary  to  operate  below  the  isth- 
mus of  the  thyroid  gland  in  the  living,  and  the  opera- 
tion on  the  cadaver  gives  an  inadequate  idea  of  the 
difficulties  encountered  in  this  location.  The  incis- 
ions must  be  made  in  the  median  line  throuo:h  the 
integument  and  fasciae.  Separate  the  sterno-hyoid  and 
sterno  -  thyroid  muscles.  Make  the  incisions  from 
below  upward,  using  the  left  index-iinger  to  locate 
the  trachea  and  to  guide  the  incisions. 

In  the  lower  angle  of  the  wound  the  left  innomi- 
nate vein,  the  innominate  artery,  a  j)lexus  formed  by 
the  inferior  thyroid  veins,  the  thyroidea  ima,  and  the 
thymus  gland  may  be  encountered. 

When  the  trachea,  which  is  deeply  situated,  is 
exposed,  hook  it  forward  and  open  it  to  the  extent  of 
an  inch  in  the  median  line.  The  tube  is  now  inserted 
and  secured. 

The  operation  of  tracheotomy  may  be  performed 


OPERATION'S  ON'  THE  HEAD  AND  NECK.  41 

by  bolder  incisions.  Include  the  trachea  between  the 
left  index-finger  on  the  left  and  the  thnmb  on  the 
right  side.  By  approximating  the  fingers  and  press- 
ing backward,  the  trachea  is  made  to  bulge  forward, 
and  the  tissues  anterior  to  it  are  put  on  the  stretch. 
Locate  the  cricoid  cartilage.  Make  an  incision  in  the 
median  line  two  inches  in  length  from  the  cricoid 
cartilage  downward.  Divide  all  the  tissues  until  the 
trachea  is  exposed.  Apply  clamps  to  the  divided 
isthmus  of  the  thyroid  gland.  Hook  the  trachea  for- 
ward, and  complete  the  operation  as  before  described. 
Before  inserting  the  tube  in  these  operations,  suck 
the  mucus  from  the  air-passage  by  means  of  a  rubber 
tube  attached  to  the  nozzle  of  an  ordinary  syringe. 

EXTEENAL    (ESOPHAGOTOMY. 

Place  the  subject  on  the  back,  with  the  shoulders 
slightly  raised  on  a  block.  Turn  the  face  to  the 
right,  as  the  oesophagus  is  most  easily  approached 
from  the  left  side,  to  which  it  inclines.  Operate  from 
the  left  side. 

Locate  the  cncoid  cartilage,  close  below  which 
the  oesophagus  is  to  be  opened.  Make  an  incision 
between  the  anterior  border  of  the  left  stemo-mas- 
toid  muscle  and  the  larynx,  beginning  at  the  level  of 
the  upper  border  of  the  thyroid  cartilage,  and  con- 
tinue this  incision  downward  two  inches  between 
the  same  muscle  and  the  trachea.  Cut  the  integu- 
ment, platisma,  and  fascige.  Draw  the  sterno-mastoid 
muscle  outward.  Separate  the  omo-hyoid  muscle,  and 
either  divide  it  or  draw  it  outward  w^ith  the  sterno- 
mastoid. 

JElevate  slightly  the  head,  to  relax  the  tissues,  so 


42  OPERATIVE  SURGERY   ON  THE  CADAVER, 

tliat  tlie  sides  of  the  wound  can  be  retracted.  Divide 
on  a  director  tlie  deep  fascia,  and  draw  the  carotid 
sheath  outward.  Separate  the  attachments  of  the 
thyroid  lobe  and  turn  it  toward  the  right. 

Pass  a  bulbous  bougie  through,  the  mouth  and 
pharynx  into  the  oesopliagus  to  the  location  where 
the  opening  is  to  be  made.  Draw  the  trachea  for- 
ward, slightly  twisting  it  over  toward  the  right  side. 
The  bulb  of  the  bougie  can  now  be  cut  directly 
upon,  or  the  wall  of  the  oesopliagus  may  be  raised 
and  a  small  opening  made  through  it  to  admit  the 
finger.  Enlarge  the  opening  vertically,  either  upward 
or  downward. 

In  making  the  opening  do  not  divide  the  recur- 
rent laryngeal  nerve,  and  in  cutting  downward  guard 
against  wounding  the  inferior  thyroid  artery. 

In  closing  the  wound  into  the  oesophagus,  stitch 
the  opening  with  a  continuous  suture  and  invert  the 
edges.  Bring  together  the  separated  muscles  by 
means  of  buried  sutures,  providing  for  drainage. 
Stitch  the  integumentary  wound. 

Pharyngotomy  is  performed  if  the  incision  into 
the  oesophagus  is  prolonged  upward  above  the  level 
of  the  cricoid  cartilage  into  the  pharynx. 

If  the  external  incision  is  continued  upward,  avoid 
cutting  the  superior  thyroid  artery  and  the  superior 
laryngeal  nerve. 


CHAPTER  V. 

OPERATIONS  ON  THE  TRUNK. 
EXCISIOI^   OF   THE   MAMMAKY    GLAND. 

The  removal  of  tlie  areolar  tissue  of  tlie  axilla 
should  be  practiced  in  conjunction  witli  this  operation. 

Place  the  subject  on  the  back,  with  the  thorax 
slightly  raised  on  a  block.  The  pectoralis  major  is 
made  tense  by  the  arm  being  abducted  to  a  right 
angle  with  the  body.  Operate  standing  on  the  side 
from  which  the  gland  is  to  be  removed. 

Begin  internal  to  the  gland  to  make  a  curved 
incision,  concave  upward,  following  closely  the  direc- 
tion of  the  fibers  of  the  pectoralis  major,  and  extend- 
ing below  the  nipple  external  to  the  gland.  Dissect 
the  integument  and  fascia  downward  until  the  lower 
border  of  the  pectoralis  major  is  reached,  which  is 
the  best  guide  to  the  lower  border  of  the  gland. 
Separate  the  lower  and  posterior  connections  of  the 
gland. 

Begin  a  second  curved  incision,  concave  down- 
ward, at  the  same  point  as  the  first,  and  extend  it  in 
the  direction  of  the  fibers  of  the  pectoralis  major 
above  the  nipple,  joining  the  first  incision  at  a  point 
external  to  the  gland.  Dissect  up  the  integument 
and  fascia  until  the  upper  border  of  the  gland  is  ex- 


44         OPERATIVE  SURGERY  ON  THE  CADAVER. 

posed.  Separate  the  upper  and  internal  connections 
of  the  gland. 

Grasp  the  gland  and  draw  it  outward.  Throw  a 
lio-ature  around  the  external  connections,  and  sever 
the  tissue  distal  to  the  ligature. 

Extend  the  incision  upward  and  outward  to  the 
middle  of  the  axilla.  Tease  out  and  separate  by 
means  of  the  fingers  the  stump  of  the  gland,  the 
areolar  tissue  along  the  inferior  border  of  the  pec- 
toralis  major,  and  in  the  whole  of  the  axillary  space. 

If  in  the  upper  part  of  the  axillary  space  any  at- 
tachments require  cutting,  they  must  first  be  ligatured 
and  then  cut  on  the  distal  side  of  the  ligatm^e. 

The  axillary  vessels  are  situated  in  the  anterior 
third  of  this  space.  In  the  operation  branches  of  the 
long  and  alar  thoracic,  intercostals,  and  internal  mam- 
mary arteries  are  divided. 

Puncture  the  lower  flap  through  its  most  depend- 
ent part.  Provide  for  drainage  through  this  punct- 
ure and  through  the  inner  angle  of  the  wound. 

Suture  the  flaps  together,  using  sutures  of  relaxa- 
tion if  there  is  any  tension. 

MEDTAIS"   LAPAEOTOMY. 

Place  the  subject  on  the  back.  Evacuate  the 
bladder.  Stand  on  the  right  side,  facing  the  abdo- 
men. 

Make  an  incision  with  a  scalpel  in  the  median 
line  of  the  abdomen  from  just  below  the  umbilicus 
to  a  point  about  an  inch  above  the  symphysis  pubis. 
Divide  the  integument  and  fascia  to  bring  into  view 
the  linea  alba.  Cut  in  the  linea  alba,  through  its 
fibrous  tissue  and  the  underlying  transversalis  fascia, 


OPERATIONS  ON  THE  TRUNK.  45 

until  tlie  areolar  tissue  over  the  peritonaeum  is  uncov- 
ered. Tease  through  this  areolar  tissue,  or  divide  it 
on  a  director.  Catch  up  very  superficially  the  peri- 
tonaeum and  nick  it  near  the  end  of  the  forceps. 
With  a  second  pair  of  forceps  seize  the  opposite  side 
of  the  small  opening,  and  tear  it  large  enough  to 
admit  the  fin2:er. 

Introduce  the  left  index-finger,  and  apply  its 
palmar  surface  to  the  peritonaeum  in  the  line  of  the 
incision.  Introduce  a  probe-pointed  bistoury  flatwise 
along  the  palmar  sui^face  of  the  finger.  Turn  its 
cutting  edge  forward  and  divide  the  peritonaeum. 

The  fm'ther  division  of  the  peritonaeum  is  best 
made,  with  a  probe-pointed  bistoury,  cutting  between 
the  left  index  and  middle  fingers,  which  draw  it  for- 
ward and  at  the  same  time  prevent  the  intestines 
slipping  in  front  of  the  knife. 

If  the  incision  is  not  large  enough,  it  must  be  pro- 
longed upward.  Divide  the  integument  and  fascia  in 
the  median  line,  avoiding  the  umbilicus  by  a  curved 
incision  around  its  left  semi-circumference.  The  in- 
cision can  now  be  completed  by  dividing  the  perito- 
naeum and  the  remaining  undivided  tissues  between 
the  index  and  middle  fingers  in  the  manner  described. 

The  contents  of  the  peritoneal  cavity  are  all  ac- 
cessible, and  can  be  examined.  To  close  the  wound, 
bring  together  the  divided  peritonaeum,  apposing  se- 
rous surfaces  by  means  of  the  quilt  or  the  continuous 
sutures.  Draw  together  the  recti  muscles  by  means 
of  buried  sutures  or  silver  sutures  of  relaxation.  Pro- 
vide for  drainage  from  the  superficial  wound.  Suture 
the  integument  and  fascia,  bringing  them  together,  if 
necessary,  by  sutures  of  relaxation. 


46  OPERATIVE  SURGERY  OIT  TEE  CADAVER. 

If  the  linea  alba  is  obscure,  and  the  sheath  of  the 
rectus  is  opened,  remember  that  posteriorly,  about 
midway  between  the  umbilicus  and  the  pubes,  the 
sheath  ends  inf eriorly  in  the  semilunar  fold  of  Douglas. 

ElS^TEEOEEHAPHY. 

Prepare  the  subject  by  stabbing  through  the  ab- 
dominal wall  or  shooting  with  a  revolver  to  wound 
the  intestine. 

Expose  the  abdominal  contents  by  means  of  me- 
dian laparotomy. 

The  different  sutures  considered  in  Chapter  III 
for  wounded  intestine  may  be  practiced  to  close  the 
wounds. 

Enterorrhaphy  may  be  employed  in  cases  where 
it  does  not  reduce  the  caliber  of  the  gut  to  less  than 
one  half  of  its  normal  size. 

EIS^TERECTOMY. 

Expose  the  abdominal  contents  by  median  lapa- 
rotomy. 

Remove  the  part  to  be  operated  upon  out  of 
the  peritoneal  cavity.  Apply  intestinal  pincers  two 
inches  below  the  line  of  the  proposed  lower  division 
of  the  intestine.  Strip  the  intestinal  contents  up- 
ward and  prevent  their  descent  by  applying  intesti- 
nal pincers  two  inches  above  the  line  of  the  proposed 
up]oer  division  of  the  intestine.  The  gut  to  be  ex- 
cised, now  being  empty  of  any  fecal  contents,  is  di- 
vided by  scissors. 

The  mesentery  attached  to  the  excised  intestine 
may  be  ligated  in  sections  near  its  attachment  and 
then  separated  by  cutting  between  the  ligatures  and 


OPERATION'S  ON  THE  TEUNK.  47 

the  intestine.  A  triangular  piece  of  the  mesentery 
may  be  removed,  the  base  of  the  triangle  being  the 
border  of  the  mesentery  attached  to  the  excised  por- 
tion of  intestine.  The  sides  of  the  triangle  are  then 
joined  by  sutures. 

A  divided  vessel  may  be  found  near  the  mesenteric 
border  of  the  divided  ends  of  the  intestine. 

Appose  the  ends  of  the  intestine  by  means  of  the 
Jobert,  Czerny-Lembert,  or  double  interrupted  suture 
if  enterorrhaphy  is  proposed. 

The  division  of  the  intestine  may  be  made  ob- 
liquely, and  the  mesenteric  border  of  one  end  sutured 
to  the  free  border  of  the  other  (Morris).  This  fulfills 
the  requirement  of  good  blood-supply  to  the  ends  of 
the  gut.  The  division  of  the  gut  is  ordinarily  made 
near  a  loop  of  the  mesenteric  artery  to  meet  this 
same  demand. 

•  Both  ends  of  the  intestine  may  be  secured  to  the 
external  wound,  and  a  fecal  fistula  be  established  as  is 
about  to  be  described. 

ET^TEROTOMY. 

Expose  the  intestines  by  median  laparotomy. 

Follow  the  mesentery  downward  to  determine 
one  of  the  lower  loops  of  the  small  intestine.  It  is 
necessary  to  be  guided  by  the  mesentery,  as  Treves 
has  shown  that  the  long  mesentery  of  the  lower 
portion  of  the  jejunum  allows  it  to  occupy  the  pelvic 
cavity. 

Remove  the  loop  selected  for  the  operation  from 
the  peritoneal  cavity.  Open  into  its  lumen  by  nick- 
ing a  fold  picked  up  by  means  of  forceps. 

Enlarge   the  wound  by  means  of  probe-pointed 


4:8  OPERATIVE  SURGERY  ON  THE  CADAVER. 

scissors,  using  the  probe-pointed  blade  in  the  lumen 
of  tlie  intestine. 

The  wound  may  be  closed  by  performing  enter- 
orrhaphy,  or  a  fecal  fistula  may  be  established, 

ENTEROSTOMY,    WITH   ENTEROTOMY   OE   EIMTEEECTOIMT. 

In  this  023eration  the  loop  of  intestine  is  brought 
to  the  lower  angle  of  the  laparotomy  incision,  or  a 
second  opening  is  made  in  a  line  with  the  fibers  of  the 
external  oblique  muscle  which  will  act  slightly  as  a 
sphincter.  An  opening  one  inch  and  a  half  long 
thi^ou^rh  the  abdominal  walls  is  made  to  lead  into  the 
lumen  of  the  gut. 

After  median  laparotomy  the  loop  of  intestine  is 
secured  by  piercing  it  with  a  ligature,  both  ends  of 
which  are  brought  out  of  the  abdominal  opening  to 
which  the  gut  is  to  be  sutured. 

Prevent  the  bulging  of  the  intestines  by  inserting 
a  sponge  through  the  wound.  Detach  the  peritonaeum 
around  the  wound  and  draw  it  up,  stitching  it  to  the 
integument  so  that  the  walls  of  the  wound  will 
present  a  serous  surface.  Remove  the  sponge  from 
the  abdominal  cavity  and  draw  upon  the  ends  of  the 
ligature  to  engage  the  loop  of  gut  in  the  wound.  A 
quarter  of  an  inch  from  the  margin  pass  a  needle  into 
the  wound  throus^h  almost  the  entire  thickness  of  the 
walls  of  the  abdomen.  Pierce  a  small  fold  of  the 
apposed  circumference  of  the  intestine.  Carry  the 
lio;ature  from  within  outward  throusrh  the  wall  of 
the  abdomen,  and  secure  its  ends  by  means  of  a  knot. 
In  like  manner,  at  intervals  of  one  quarter  of  an  inch, 
stitch  the  intestine  to  the  walls  of  the  wound. 

Open  the  intestine  nearly  to  the  extent  of  the 


OPEBATIONS  OR  THE  TRUNK.  49 

wound,  and  pass  a  sponge  into  its  lumen  to  prevent 
the  escape  of  any  matter.  Suture  the  cut  edges  of 
tlie  intestine  and  of  the  skin  together,  by  means  of 
the  continuous  suture. 

If  a  fistula  is  to  be  established  with  enterectomy, 
the  enterectomy  may  first  be  performed,  and  the  two 
ends  of  the  intestine  brous^ht  to  the  abdominal  wound. 
The  lower  end  is  sutured  by  means  of  the  quilt  suture- 
to  one  side- wall  of  the  wound,  with  its  end  fl.ush  with 
the  integument.  The  upper  end  must  be  sutured  as 
after  enterotomy,  no  regard  being  paid  to  the  presence 
of  the  lower  end. 

The  lumen  of  the  lower  end  may  be  closed  by  the 
Czerny-Lembert  suture,  and  the  end  then  allowed  to 
remain  free  in  the  abdominal  cavity. 

COLECTOMY. 

Follow  the  same  rules  given  for  the  performance 
of  enterectomy.  It  is  best  to  establish  a  fecal  fistula 
by  attaching  the  upper  end  of  the  gut  to  the  wound, 
the  lower  end  being  returned  into  the  abdominal  cavity 
after  closing  its  lumen  by  the  Czerny-Lembert  suture. 

Colotomy  is  governed  by  the  same  rules  as  those 
for  enterotomy. 

LUMBAR    COLOSTOMY. 

This  operation  may  be  performed  either  on  the 
right  side  into  the  ascending  colon,  or  on  the  left  side 
into  the  descending  colon. 

Place  the  subject  midway  between  the  side  and 
prone  positions,  with  a  block  under  the  loin  to  render 
tense  and  prominent  the  site  of  the  operation. 

Bisect  aline  joining  the  anterior  and  posterior 
superior  spinous  processes  of  the  ilium,  and  one  half 


50  OPERATIVE  SURGERY  ON  THE  CADAVER. 

incli  posterior  to  tMs  point  erect  a  perpendicular  ex- 
tendins:  to  the  last  rib. 

Make  an  incision  about  four  inches  long,  having 
the  median  point  of  the  perpendicular  line  as  its  me- 
dian point.  This  incision  should  extend  downward 
and  forward  parallel  to  the  last  rib.  Divide  the  in- 
tegument and  fasciae,  the  outer  edge  of  the  latissi- 
mus-dorsi  muscle,  and  the  posterior  free  edge  of  the 
external  oblique  muscle.  Divide  the  internal  oblique 
and  transversalis  muscles,  and  expose  the  external 
borders  of  the  erector  spinse  and  quadratus  lumbo- 
rum  muscles.  Divide  the  transversalis  fascia,  and  ex- 
pose the  areolar  tissue  lying  posterior  to  the  colon. 

Retract  toward  the  spine  the  quadratus  lumbo- 
rum  muscle.  Tease  through  the  areolar  tissue,  and 
above  feel  the  lower  rounded  end  of  the  kidney. 

Inflate  the  colon  by  forcing  air  by  the  anus 
through  the  rectum.  The  colon  is  felt  immediately 
below  and  in  front  of  the  lower  end  of  the  kidney. 

Divide  slightly  the  outer  border  of  the  quadratus 
lumborum  muscle.  Tease  through  the  areolar  tissue 
until  the  colon  is  uncovered. 

Draw  up  into  the  wound  by  means  of  forceps  the 
posterior  and  inner  wall  of  the  colon.  One  inch  from 
each  angle  of  the  wound  pass  a  ligature  deeply 
through  the  tissues  to  corresponding  points  on  the 
other  side  of  the  wound.  These  ligatures  will  pierce 
the  portion  of  gut  engaged  in  the  wound.  Make  a 
longitudinal  opening,  about  one  inch  long,  into  the 
lumen  of  the  gut.  Hook  up  the  ligatures  as  they 
traverse  the  lumen  of  the  intestine  and  divide  them, 
thus  making  four  sutures.  Secure  these  sutures, 
which  will  prevent  the  gut  from  receding. 


OPERATIONS  ON  THE  TRUNK.  51 

Insert  a  sponge  into  tlie  lumen  of  tlie  intestine^ 
and  stitcli  the  edges  of  tlie  intestinal  opening  to  the 
integument  on  each  side  of  the  wound.  Appose  the 
angles  of  the  wound  by  sutures. 

If  the  peritoneal  cavity  is  opened,  stitch  the  peri- 
toneal wound,  providing  for  drainage,  and  bring  the 
abdominal  wound  together.  The  operation  should 
be  tried  in  the  opposite  loin.  The  ascending  more 
often  than  the  descending  colon  is  attached  to  the 
abdominal  parietes  by  a  meso-colon. 

The  incision  for  colostomy,  when  prolonged  into 
the  quadratus  lumborum  muscle  until  the  finger  can 
touch  the  transverse  process  of  a  lumbar  vertebra,  is 
to  be  recommended  in  opening  a  psoas  abscess.  Tease 
a  way  with  the  finger  along  the  anterior  surface  of 
the  transverse  process,  where  an  opening  into  the 
sheath  of  the  psoas  muscle  can  be  made. 

:n^ephroeehaphy. 

Place  the  subject  in  the  same  position  as  for  lum- 
bar colostomy. 

Make  an  incision,  parallel  and  similar  to  that  for 
lumbar  colostomy,  one  inch  nearer  the  lower  border 
of  the  twelfth  rib.  The  tissues  are  divided,  and  the 
fat  enveloping  the  kidney  teased  through  to  expose 
the  posterior  surface  of  the  capsule. 

Press  on  the  abdominal  wall  to  engage  the  kidney 
in  the  wound.  Divide  on  a  director  the  capsule  of 
the  kidney  and  strip  it  from  the  organ  to  the  extent 
of  one  half  of  an  inch  or  more.  Draw  upon  the  cap- 
sule and  stitch  it  to  the  sides  of  the  wound. 

Leave  the  wound  open. 


52  OPERATIVE  SURGERY  ON  THE  CADAVER. 

KEPHEOTOMY. 

Expose  the  posterior  surface  of  the  kidney  as  in 
the  last  operation. 

Cut  through  the  cortical  substance  as  if  to  expose 
a  calculus.  The  location  of  the  incision  is  determined 
by  systematic  search  with  the  exploring  needle. 

The  pelvis  of  the  kidney  should  be  explored  by  di- 
\dding  the  organ  parallel  to  the  Malpighian  pyramids. 

Is^EPHEECTOMY. 

Expose  the  kidney.  Separate  by  means  of  the 
fingers  the  kidney  fi'om  the  surrounding  areolar  tis- 
sue. Separate  the  ureter  from  the  vessels.  With  an 
aneurism-needle  pass  a  ligature  around  the  vessels  and 
ligate  them  a  little  distance  from  the  kidney.  Divide 
the  vessels  distal  to  the  ligature,  and  remove  the  kid- 
ney still  attached  to  the  ureter.  Divide  the  ureter 
near  the  pelvis  of  the  kidney.  Invert  the  edges  and 
close  the  caliber  of  the  ureter  by  stitches,  after  which 
it  can  be  returned  into  the  wound.  Ligate  separately 
the  vessels  in  the  pedicle.  Provide  di'ainage,  and 
close  the  wound. 

After  the  vessels  are  ligated,  the  kidney  may  be 
removed  in  halves  if  it  is  enlarged. 

SYMPHYSIOTOMY. 

Place  the  subject  on  the  back.  Shave  the  hair 
from  over  the  pubes.  Distend  the  bladder.  Stand 
on  the  right-hand  side  of  the  patient. 

Make  an  incision  in  the  median  line  of  the  body 
from  a  point  one  inch  above  the  upper  margin  to  the 
level  of  the  lower  margin  of  the  symphysis  j)ubis. 


OPEEATIOI^S  OIT  THE  TRUNK.  53 

Divide  tlie  integument  and  fascia  above  and  all  the 
tissues  over  tlie  symphysis.  By  means  of  a  periosteal 
elevator  push  aside  the  tissues  on  each  side  of  the  in- 
cision over  the  symphysis,  clearing  the  bones  to  the 
extent  of  one  half  of  an  inch.  Separate  the  pyrami- 
dales  and  recti  muscles  at  their  junction  in  the  median 
line. 

Evacuate  the  bladder.  With  the  fingers  clear  the 
attachments  above,  behind,  and  below  the  symphysis 
pubis.  Pass  a  chain-saw  behind  the  symphysis.  Pro- 
tect the  tissues  behind  and  below  by  means  of  spatulse 
while  the  symphysis  is  sawn  through. 

The  diameters  of  the  pelvis  may  be  increased  or 
the  anterior  vesical  wall  uncovered  by  separating. the 
pubic  bones. 

The  ligaments  joining  the  ilia  to  the  spinal  column 
are  stretched  or  partially  ruptured  when  the  pubic 
bones  are  drawn  apart. 

To  close  the  wound,  the  pubic  bones  are  to  be 
wired,  drainage  provided,  and  the  wound  stitched 
(see  Chapter  IX). 


CHAPTER  VI. 

QENITO  -  VESICAL. 
EXTERI^AL   PERIT^EAL  URETHROTOMY. 

Place  tlie  subject  on  the  back,  and  tie  tlie  wrist 
and  ankle  of  eack  side  together.  Draw  tke  buttock 
to  tke  edge  of  tke  table  and  separate  tke  tkigks. 
Skave  tke  perinseum.     Sit  facing  tke  perinseum. 

Pass  a  sound  kaving  a  groove  on  its  convexity 
into  tke  bladder.  An  assistant  must  kold  tke  sound 
perpendicularly  in  tke  median  line,  drawing  sligktly 
toward  tke  pubes,  at  tke  same  time  kolding  up  tke 
scrotum.  Make  an  incision  in  tke  median  line  of  tke 
perinseum  one  inck  and  a  kalf  long,  ending  one  kalf 
inck  anterior  to  tke  anus.  Divide  tke  integument 
and  fasciae.  Incise  tke  tissues  in  tke  median  line  un- 
til tke  groove  of  tke  instrument  can  be  felt.  Guide 
witk  tke  left  index-finger  tke  point  of  a  narrow  knife 
into  tke  groove. 

1.  Run  tke  knife  along  tke  groove  to  tke  apex  of 
tke  prostate. 

2.  Cut  an  opening  tkree  quarters  of  an  inck  long 
into  tke  uretkra  by  running  tke  knife  along  tke  groove. 
Pass  a  ligature  tkrougk  eack  side  of  tke  uretkral  wound. 
"Witkdraw  tke  sound  to  imitate  tke  case  of  an  impass- 
able obstruction.     By  drawing  on  tke  ligatures  tke 


GENITO-VESICAL.  55 

urethral  canal  is  opened.  Pass  a  probe  into  the  blad- 
der as  a  guide. 

3.  Dissect  in  the  median  line  to  the  apex  of  the 
prostate,  or  upon  the  end  of  a  bougie  passed  by  pos- 
terior catheterization  to  imitate  cases  where  no  exter- 
nal opening  can  be  discovered. 

Leave  the  wound  open. 

SOUl^DU^a   FOE    STONE. 

Place  the  subject  on  the  back,  with  the  buttock 
elevated  on  a  block.  Pass  into  the  bladder  through 
the  perineal  wound  a  small  piece  of  chalk. 

Stand  on  the  left  side  and  introduce  a  ThomjD- 
son's  searcher.  Its  passage  through  the  membranous 
urethra  occurring  when  the  searcher  is  vertical  may  be 
aided  by  pressure  over  the  pubes  to  relax  the  suspen- 
sory ligament  of  the  penis,  or  by  pressure  over  the 
convexity  of  the  curve  of  the  searcher  as  it  bulges  the 
perinseum.  Inject  through  the  searcher  about  five 
ounces  of  water. 

Stand  between  the  thighs.  Make  the  beak  of  the 
instrument  follow  every  part  of  the  walls  of  the  blad- 
der. By  twirling  the  handle  slightly,  the  beak  is 
made  to  rap  lightly  against  the  walls.  To  explore 
behind  the  prostate,  insert  the  left  index-finger  into 
the  rectum  and  push  upward  toward  the  inverted 
beak  of  the  searcher.  Aid  the  exploration  of  the  an- 
terior wall  by  pressing  above  the  pubes. 

In  the  female,  pass  the  searcher  as  a  catheter.  Aid 
the  exploration  by  the  finger  in  the  vagina. 

The  click  made  by  striking  the  stone  may  be  in- 
creased by  attaching  a  sounding-board,  or  by  fasten- 
ino*  one  end  of  a  rubber  tube  to  the  instrument  and 


56  OPERATIVE  SURGERY  OJST  THE  CADAVER. 

insertino^  the  other  end  into  the  ear.  If  more  than 
one  piece  of  chalk  be  inserted,  a  click  may  be  ob- 
tained after  one  piece  is  held  in  the  forceps. 

LITHOTPvITY. 

Eemove  the  searcher  and  introduce  a  lithotrite, 
allowing  it  to  enter  the  bladder  by  its  own  weight. 

Lithotrity  may  be  performed  through  the  urethra  or 
through  the  opening  made  by  external  urethrotomy. 

When  the  lithotrite  touches  the  chalk,  turn  the 
beak  away  and  open  its  blades.  Turn  the  separated 
blades  toward  the  chalk,  and  engage  it  between  them. 
Close  the  blades  to  confine  the  chalk.  Raise  the  chalk 
from  the  mucous  membrane  and  crush  it  by  screwing 
the  lever  quickly  once  or  twice.  The  large  fragments 
fall  close  to  the  instrument  and  can  be  easily  picked 
up.  The  chalk  may  be  caught  by  pressing  the  con- 
vexity of  the  lithotrite  against  the  base  of  the  blad- 
der and  allowing  it  to  fall  between  the  open  blades. 
The  crushing:  should  be  done  in  the  center  of  the 
cavity  of  the  bladder. 

The.  debris  of  the  chalk  may  be  removed  at  once 
by  means  of  an  evacuator  ("  rapid  lithotrity  "  of  Big- 
elow).  Remove  the  lithotrite  and  introduce  an  evacu- 
ating catheter  (Keyes's).  Attach  the  washer  filled 
with  water.  By  pressing  the  bulb  of  the  washer,  it 
is  partially  emptied  into  the  bladder.  When  the 
pressure  is  removed,  the  bulb,  resuming  its  shape, 
causes  a  current  of  water  into  the  washer,  which  car- 
ries with  it  small  particles  of  the  chalk.  The  particles 
sink  into  the  receptacle  below  the  washer. 

LarG^e  f  ragraents  cause  a  "  click  "  when  carried 
ao:ainst  the  catheter.     The  remaiuinor  fracfments  must 


GEmTO-VESIGAL.  57 

be  crushed,  and  tlie  washing  continued  until  all  are 
removed.  Hold  the  lithotrite  steady  while  crushing 
the  chalk,  and  be  sure  that  the  blades  are  in  contact 
before  beginning  its  removal.  Bryant's  catheter  and 
crusher  combined  prevents  the  change  of  instru- 
ments after  the  first  crushing. 

In  perineal  lithotrity,  a  large  lithotrite  and  evac- 
uating catheter  may  be  used  without  lacerating  the 
tissues ;  also  the  same  applies  to  lithotrity  through 
the  female  urethra. 

CYSTOTOMY. 

1.  Median  Perineal  Cystotomy. — Place  the  sub- 
ject as  for  external  urethrotomy. 

Pass  a  grooved  staff  into  the  bladder  which  is 
held  as  in  external  urethrotomy.  Insert  the  oiled 
left  index-finger  into  the  rectum  to  feel  the  apex  of 
the  prostate. 

Puncture  the  perinseum  one  half  inch  above  the 
anus  in  the  median  line,  directing  the  point  of  the 
knife  with  its  edge  turned  upward  nearly  to  the 
apex  of  the  prostate.  While  withdrawing  the  knife, 
cut  upward  in  the  median  line  to  the  extent  of  one 
inch. 

Remove  the  finger  from  the  rectum.  Guide  the 
knife  with  its  edge  directed  downward,  until  its 
point  is  in  the  groove  of  the  staff,  a.  Push  the 
knife  along  the  groove  into  the  bladder,  h.  After 
the  urethra  has  been  divided,  a  grooved  director  may 
be  passed  along  the  staff,  after  which  the  staff  may 
be  withdrawn.  The  neck  of  the  bladder  may  now 
be  incised  upward. 

Introduce  the  finger  along  the  guide  into  the 
bladder,  and  examine  the  interior. 


58  OPERATIVE  SURGERY  ON  TEE  CADAVER. 

(Removal  of  a  piece  of  chalk  by  means  of  for- 
ceps may  be  practiced.  Introduce  the  forceps  along 
a  guide  and  grasp  the  chalk  in  its  long  axis.  In 
removing  the  forceps  holding  the  chalk,  draw  down- 
ward, moving  the  handle  of  the  forceps  from  side 
to  side  without  rotation.) 

Introduce  through  the  wound  a  chemise  catheter 
into  the  bladder.  Pack  the  catheter  by  filling  the 
space  between  the  chemise  and  the  catheter,  thus 
exerting  pressure  on  the  walls  of  the  wound. 

2.  Vaginal  Cystotomy, — Place  the  subject  as  in 
the  last  operation.  Retract  the  posterior  vaginal 
wall  with  a  Sims's  speculum.  Inject  into  the  bladder 
four  or  fiYQ  ounces  of  water  through  a  catheter  and 
then  plug  the  catheter. 

Hold  the  catheter  so  that  it  bulges  the  anterior 
vaginal  wall.  Through  the  vagina  divide  the  tissues 
in  the  median  line,  cutting  on  the  catheter  to  the  ex- 
tent of  an  inch.  The  incision  should  be  made  from 
behind  forward,  and  care  must  be  taken  not  to  incise 
the  cervix  posteriorly,  nor  the  urethra  anteriorly. 
The  interior  of  the  bladder  is  readily  explored  by  the 
finger. 

Close  the  wound  by  the  continuous  suture  from 
behind  forward.  Draw  the  vaginal  wall  forward  by 
means  of  tenacula,  to  facilitate  the  closing  of  the 
wound  by  sutures. 

3.  Lateral  Perineal  Cystotomy, — The  subject  is 
placed  in  the  same  position  as  for  the  median  operation. 

a.  In  the  Male. — Pass  a  grooved  staff  into  the 
bladder,  which  is  to  be  held  perpendicularly,  the  scro- 
tum being  raised  by  the  same  hand  of  the  assistant. 

Begin  an  incision  just  to  the  left  of  the  median 


'       GENITO-VESIGAL.  59 

point  of  the  raplie,  wMcli  extends  from  tlie  anus  to 
tlie  scrotum,  and  continue  it  downward  and  outward 
to  a  point  half-way  between  the  tuber  ischii  and  the 
anus.  Divide  the  tissues  in  this  line  until  the  groove 
in  the  staff  can  be  felt.  Guide  the  point  of  the  knife, 
with  its  edge  turned  downw^ard,  into  the  groove. 
Push  the  knife,  depressing  its  handle  if  the  staff  is 
curved,  to  make  the  point  run  in  the  groove  into  the 
bladder.  Incise  the  neck  of  the  bladder  and  the 
prostate,  while  withdrawing  the  knife  in  a  more  hori- 
zontal line  than  the  skin  incision.  The  finger  intro- 
duced along  the  staff  can  now  examine  the  interior 
of  the  bladder. 

The  left  transversus  perinei  and  superficial  peri- 
neal arteries  may  be  ligated. 

To  avoid  wounding  the  rectum,  introduce  the  left 
index-finger  while  cutting  the  tissues. 

Introduce  a  chemise  catheter  as  in  the  last  oper- 
ation. 

h.  In  the  Female. — The  position  is  the  same  as 
that  for  operation  on  the  male  subject. 

Pass  a  grooved  staff  into  the  bladder.  Begin  an 
incision  just  to  the  left  of  the  clitoris,  and  continue  it 
downward  and  outward  one  inch  and  a  half  parallel 
to  the  descending  ramus  of  the  pubes  and  ascending 
ramus  of  the  ischium.  Incise  the  tissues  in  this  line 
until  the  groove  of  the  staff  can  be  felt  near  the  neck 
of  the  bladder.  Guide  the  point  of  the  knife  along 
the  nail  of  the  left  index -finger  into  the  groove  of  the 
staff,  and  incise  the  neck  of  the  bladder  downward 
and  outward  in  the  line  of  the  incision.  To  avoid 
wounding  the  vagina,  introduce  the  finger  while  in- 
cising the  tissues. 


60  OPERATIVE  SURGERY  ON'  TEE  CADAVER. 

The  iinger  can  easily  explore  tlie  interior  of  the 
bladder  throus-h  the  incision. 

Supra])uhiG  Cystotomy. — Place  the  subject  on  the 
back,  and  shave  the  hair  from  over  the  pubes.  Insert 
into  the  rectum  beyond  the  external  sphincter  a  rub- 
ber bag.  Distend  the  bag  with  about  twelve  ounces 
of  water,  after  introducing  a  catheter  into  the  bladder. 
Inject  into  the  bladder  through  the  catheter  from  six 
to  ten  ounces  of  water,  and  plug  the  catheter. 

Stand  on  the  left-hand  side  and  begin  an  incision 
over  the  symphysis  pubis,  extending  upward  three 
inches  in  the  median  line  of  the  body.  Divide  the 
integument  and  fasciae.  Separate  the  pyramidales 
and  recti  muscles.  Divide  the  fascia  transversalis  on 
a  director,  and  tease  through  the  areolar  tissue  imme- 
diately above  the  symphysis  pubis,  until  the  bladder- 
wall  is  uncovered.  The  bladder  is  recognized  by  its 
muscular  fibers,  its  vessels,  its  color,  and  its  feel  against 
the  beak  of  the  catheter. 

With  the  fingers  separate  the  areolar  tissue  from 
the  bladder  upward,  to  the  extent  of  two  inches. 
Ketract  the  areolar  tissue,  and  hook  a  tenaculum  into 
the  bladder  on  each  side  of  the  median  line.  Make 
the  point  of  the  catheter  to  bulge  in  the  wound,  and 
examine  the  overlying  tissue. 

Direct  with  the  left  index-finger  the  point  of  the 
knife  to  the  upper  limit  of  the  exposed  bladder- wall. 
Pierce  the  bladder- wall,  holding  the  knife  with  its 
edge  turned  downward.  Divide  the  bladder-wall  in 
the  median  line  down  to  the  symphysis  pubis. 

Examine  the  interior  of  the  organ  with  the  finger. 
(In  introducing  the  forceps  the  tenacula  must  still 
retain  their  hold  to  prevent  the  walls  of  the  bladder 


GENITO-  VESICAL.  6 1 

from  being  pushed  backward.)  Allow  the  water  to 
escape  from  the  rubber  bag. 

Insert  into  the  bladder  through  the  wound  the 
end  of  a  large  drainage-tube,  leaving  the  other  end 
outside.  Stitch  the  wound.  Remove  the  bag  from 
the  rectum. 

In  the  adult  female,  the  vagina  instead  of  the 
rectum  may  be  distended  with  the  rubber  bag. 

POSTERIOR    CATHETERIZATION. 

This  requires  a  suprapubic  cystotomy.  The  open- 
ino*  into  the  bladder  is  made  lar^^e  enouo-h  to  admit 

O  O  CD 

the  index-fino:er  and  a  bous^ie. 

Follow  with  the  left  index-fino:er  the  anterior  w^all 
of  the  bladder  downward  in  the  median  line.  Feel 
the  smooth  floor  of  the  bladder  at  the  neck  (trigone) 
and  hook  the  iinger  forward  into  the  urethral  open- 
ing. Pass  a  bougie  along  the  finger,  and  direct  it 
into  the  urethra. 

The  end  of  the  bouo-ie  can  be  felt  throuo^h  the 
perinseum.  The  bougie  may  be  passed  through  the 
whole  length  of  the  urethra. 

RESECTIOJN^    or    THE    SCROTUM. 

Place  the  subject  on  the  back.  If  the  operation 
be  practiced  on  one  side,  the  testicle  of  that  side  must 
be  pushed  up  to  the  external  abdominal  ring. 

Stretch  uniformly  the  half  of  the  scrotum  to  be 
operated  upon.  Make  a  row  of  interrupted  quilt  su- 
tures one  half  inch  above  the  proposed  section  at  in- 
tervals of  one  quarter  of  an  inch.  Allow  sufficient 
space  for  the  introduction  of  drainage-tubes,  by  omit- 
ting the  first  and  last  sutures.     The  line  of  sutures 


G2  OPERATIVE  SURGERY   OIT  THE   CADAVER. 

sliould  make  an  acute  angle  with  tlie  median  raphe 
of  the  scrotum. 

Sever  the  part  of  the  scrotum  one  half  inch  below 
the  line  of  quilt  sutures.  Introduce  the  drainage- 
tubes,  and  bring  the  edges  together  by  means  of  the 
continuous  suture. 

If  the  operation  be  bilateral,  both  testicles  are 
pushed  upward  near  the  external  abdominal  rings. 
The  row  of  sutures  is  made  horizontally  or  slightly 
curved,  mth  the  concavity  upward,  across  the 
stretched  scrotum.  Allow  for  drainage  at  each  end. 
Sever  the  portion  of  the  scrotum  one  half  inch  below 
the  row  of  quilt  sutures,  and  proceed  as  in  case  of 
the  unilateral  operation.  Several  small  arteries  may 
be  found  and  ligated. 

Henry's  clamp,  if  used,  simplifies  the  operation. 

CIECUMCISIO^. 

Place  the  subject  on  the  back.  Mark  the  skin 
of  the  prepuce  on  a  level  with  the  meatus  of  the 
urethra. 

Catch  the  end  of  the  foreskin*  above  with  a  pair 
of  forceps,  and  with  a  second  pair  catch  the  end  be- 
low. One  of  the  blades  of  each  forceps  should  fasten 
the  mucous  membrane,  and  the  other  the  skin.  Pull 
upon  the  forceps,  at  the  same  time  separating  them 
to  put  the  foreskin  on  the  stretch.  Clamp  the  fore- 
skin on  a  line  with  the  mark  made  before  it  was 
stretched.  (The  clamp  should  be  placed  perpendicu- 
larly and  not  obliquely,  as  often  advised.)  Sever  the 
portion  of  the  foreskin  beyond  the  clamp.  The  ar- 
tery of  the  frsenum  may  be  ligated. 

The  skin  will  retract  so  as  to  uncover  about  one 


GENITO-YESICAL,  63 

half  of  the  glans  penis.  Slit  up  the  mucous  mem- 
brane in  the  median  line  along  the  dorsum  to  the 
level  of  the  retracted  skin.  Pare  off  the  mucous 
membrane  in  a  line  from  the  lower  border  of  the 
meatus  urinarius  to  the  central  point  of  a  line  along 
the  middle  of  the  dorsum  of  the  glans  penis. 

Separate  any  adhesions  of  the  mucous  membrane 
to  the  glans.  Stitch  the  contiguous  cut  edges  of  the 
skin  and  mucous  membrane  together. 

The  mucous  membrane  is  shortest  along  the  dor- 
sum, and  the  skin  is  cut  circularly,  hence  the  result- 
ing foreskin  slants  obliquely  do^vnward  and  forward. 
The  fraenum  permanently  secures  this  shape  to  the 
new  foreskin. 

AMPUTATIONS"    or   THE   PEiS^IS. 

Place  the  subject  on  the  back. 

Pierce  the  penis  horizontally  from  side  to  side, 
between  the  corpora  cavernosa  and  the  corpus  spon- 
giosum, with  an  acupressure-needle.  The  penis  must 
be  pierced  nearer  the  body  than  the  line  of  the  am- 
putation. Tie  a  tape  around  the  ]3enis  above  the  acu- 
pressure-needle. Divide  the  integument  circularly 
one  half  inch  below  the  pro^^osed  division  of  the  cor- 
pora cavernosa.  Retract  the  skin  and  divide  with  a 
narrow-bladed  knife  the  cor^oora  cavernosa.  Turn 
the  edge  of  the  knife  forward  and  cut  between  the 
corpora  cavernosa  and  the  corpus  spongiosum.  Di- 
vide the  corpus  spongiosum  one  half  inch  in  front  of 
the  division  of  the  corpora  cavernosa.  The  dorsal 
arteries  of  the  penis  and  the  arteries  of  the  corpora 
cavernosa  may  be  ligated. 

Divide  the  protruding  corpus  spongiosum  verti- 


6i  OPERATIVE  SURGERY  OJST  THE  CADAVER. 

cally,  and  stitcli  tlie  angles  to  the  integument.     Re- 
move tlie  acupressm^e-needle,  also  the  tape. 

SHORTENINa    OF    THE    ROUND    LIGAMEJSTTS. 

Place  the  subject  on  the  back.  Shave  the  hair 
from  the  mons  veneris. 

Begin  an  incision  just  above  the  spine  of  the 
pubes,  and  continue  it  three  inches  outward  and 
slightly  upward,  parallel  to  Poupart's  ligament.  Cut 
the  integument  and  fasciae,  and  expose  the  aponeurosis 
of  the  external  oblique  with  the  intercolumnar  fibers 
joining  the  tAvo  pillars  of  the  external  abdominal 
rino".  Divide  the  intercolumnar  fascia,  and  nick  the 
aponeurosis  of  the  external  oblique,  to  expose  the 
contents  of  the  ins-uinal  canal. 

o 

The  round  ligament  is  readily  known  by  the 
direction  of  its  fibers.     It  is  enveloped  in  fat. 

Carefully  separate  the  exposed  portion  of  the 
round  ligament  from  its  attachments.  Draw  upon 
the  round  ligament,  at  the  same  time  having  the 
uterus  pushed  forward  by  an  assistant's  finger  in  the 
vaofina.  The  lio;ament  will  become  relaxed.  If  a 
loop  of  an  inch  or  more  in  circumference  is  now 
formed,  the  remainder  of  the  ligament  becomes 
taut. 

Repeat  the  operation  on  the  opposite  round  liga- 
ment. 

Draw  the  loops  of  the  ligaments  inward,  and  stitch 
them  to  the  deep  fascia  above  the  pubes. 

Stitch  the  divided  aponeuroses  of  the  external 
obliques  ;  also  the  pillars  of  the  rings. 

Provide  for  drainage,  and  stitch  the  wounds. 


GENITO-VESIGAL,  65 

CASTKATIOX. 

Place  the  subject  on  the  back. 

Stretch  the  scrotal  coverino^s  over  the  testis.  Be- 
gin  an  incision  just  below  the  external  abdominal 
ring,  and  continue  it  downward  over  the  testis  to 
the  bottom  of  the  scrotum.  Divide  the  tissues  over 
the  cord.  Separate  the  cord,  and  throw  around  it  a 
silk  ligature,  leaving  the  ends  of  the  ligature  hanging. 
Divide  the  cord  between  the  ligature  and  the  testis. 
Seize  the  testis  by  means  of  forceps,  and  cut  its  at- 
tachments to  the  scrotum.  Ligate  the  spermatic 
artery,  artery  of  the  vas  deferens,  and  the  cremasteric 
artery. 

Separate  the  silk  ligature  from  the  cord.  Provide 
for  drainage  from  the  bottom  of  the  wound.  Ap- 
proximate the  cut  edges  by  mean^  of  the  continuous 
suture.  A  row  of  quilt  sutures  should  be  made  one 
half  inch  from  the  margin  of  the  wound,  as  after  re- 
section of  the  scrotum. 

OOPHORECTOMY. 

Place  the  subject  on  the  back.  Shave  the  hair 
from  the  hypogastric  region  and  from  the  mons  ven- 
eris.    Empty  the  bladder. 

Perform  a  median  laparotomy,  beginning  the  in- 
cision one  inch  above  the  pubes,  and  continuing  it 
upward  four  inches.  (Remember  that  the  sheath  of 
the  rectus  is  deficient  for  the  lower  half  of  the  dis- 
tance between  the  umbilicus  and  the  symphysis.)  If 
muscular  fibers  are  divided  in  the  wound,  the  above 
caution  is  pertinent. 

Push  the  intestines  aside,  and  feel  along  the  pos- 


QQ  OPERATIVE  SUEGERY  ON  THE  CADAVER. 

terior  surface  of  the  broad  ligament  for  the  ovary. 
Separate  any  accidental  attachments,  and  draw  the 
ovary  up  to  the  wound.  Transfix  the  attachment  of 
the  ovary  by  a  needle  carrying  a  double  ligature. 
Any  large  vein  or  the  tube  must  be  avoided.  The 
needle  should  not  have  cutting  edges.  Cut  the 
ligature  from  the  needle,  and  tie  each  half  of  the 
transfixed  tissue  separately.  Sever  the  attachment 
of  the  ovary  between  the  ligatures  and  the  ovary . 

The  contiguous  portion  of  the  Fallopian  tube  is 
generally  removed  with  the  ovary.  Ligate  any  ves- 
sel that  can  be  discovered.  Kemove  with  a  small 
scoop  or  cauterize  the  lining  mucous  secreting  cells 
of  the  Fallopian  tube  on  the  cut  surface  of  the  pedi- 
cle. Allow  the  pedicle  to  drop  back  into  the  peri- 
toneal cavity. 

The  other  ovary  may  be  likewise  removed. 

Perform  the  abdominal  toilet,  and  then  close  the 
external  wound  after  providing  for  superficial  drain- 
age. 


CHAPTER  VII. 

MANIPULATION    OF    TENOTOME,    MYOTOMY,     TENOTOMY, 
FASCIATOMY,  SUTURING   OF  TENDONS. 

MAKIPULATIO]^    OF    TENOTOME. 

1.  How  to  hold. — ^Hold  tlie  tenotome  as  a  pen. 

2..  How  to  use. — Enter  the  point  of  tlie  tenotome 
perpendicularly  to  tlie  surface.  The  blade  must  be 
advanced  with  its  side  parallel  to  the  tissue  to  be 
divided.  The  point  must  reach  to  the  distal  border 
of,  but  not  beyond,  the  tissue  to  be  divided.  When 
the  flat  of  the  blade  is  in  contact  with  the  whole  tis- 
sue to  be  severed,  turn  the  handle  of  the  tenotome 
to  present  the  edge  at  a  right  angle. 

Make  the  edge  cut  with  a  slight  sawing  move- 
ment. 

When  the  tissue  is  divided,  withdraw  the  teno- 
tome in  the  same  manner  that  it  was  introduced. 

Sterno-chido-mastoid. — Place  the  subject  on  the 
back.  Turn  the  head  from  the  side  to  which  the 
muscle  belongs,  to  make  it  taut.  Stand  on  the  same 
side  as  the  muscle. 

The  muscle  can  be  clearly  located.  Draw  the 
integument  inward  over  the  sternal  attachment. 
Enter  the  sharp  point  of  the  tenotome  over  the  ex- 
ternal border  of  the  tendon,  and  with  a  slight  move- 


68  OPERATIVE  SURGERY  ON  THE  CADAVER. 

ment  of  tlie  point  cut  the  fascia  along  tlie  external 
border.  Withdraw  the  tenotome,  and  introduce  a 
probe-pointed  tenotome  to  the  outer  border  of  the  ten- 
don, lielax  the  muscle  by  turning  the  head  slightly 
to  the  side  of  the  operation.  Introduce  the  probe- 
pointed  tenotome  beneath  the  tendon,  following  its 
posterior  surface  to  its  inner  border.  Place  the  left 
thumb  so  that  the  tendon  will,  lie  between  it  and  the 
tenotome.  Make  the  tendon  taut  by  turning  the 
head  away.  Divide  the  tendon,  making  pressure 
with  the  left  thumb  at  the  same  time  over  the  tendon. 

The  thumb  can  appreciate  with  great  accuracy  the 
advancing  edge,  and  regulate  accordingly  the  required 
movement  of  the  tenotome  and  pressure  of  the  tissue 
against  its  edge. 

When  the  tendon  is  divided,  begin  to  withdraw 
the  tenotome.  Follow  the  tenotome  as  it  is  being 
withdrawn  with  the  left  thumb,  until  the  thumb  is 
over  the  wound.  As  soon  as  the  wound  is  uncovered, 
close  it  with  a  square  piece  of  plaster,  to  prevent  the 
entrance  of  air  into  the  track  of  the  knife  and  the 
space  made  by  the  retracted  tendon. 

To  divide  the  clavicular  attachment,  draw  the 
integument  inward,  and  pass  the  tenotome  as  before 
from  without  inward  beneath  the  tissue  to  be  di- 
vided.    Proceed  as  in  the  former  operation. 

The  division  of  this  muscle  at  the  level  of  the 
spinal  accessory  nerve  will  be  considered  in  the  op- 
eration of  neurotomy  of  the  spinal  accessory. 

Flexors  Suhlimis  and  Profundus  Digitorum  and 
Longus  Pollicis. — Supinate  the  forearm,  t'o  bring  the 
palm  of  the  hand  uppermost. 

Pinch  up  the  tissues  over  the  middle  of  the  proxi- 


MANIPULATION  OF  TENOTOME.  69 

mal  phalanx  with  the  left  index-finger  and  thumb. 
Enter  the  tenotome  beneath  the  fold  of  tissue  pinched 
up.  Extend  the  finger,  and  divide  the  tendons  toward 
the  bone.     Close  the  wound  as  described. 

Extensor  Coonmunis  Digitorum,  Extensors  Primi 
and  Secundi  Internodii  Pollicis. — Pronate  the  fore- 
arm to  bring  the  dorsum  of  the  hand  uppermost. 

Pinch  up  the  integument  near  the  head  of  the 
metacarpal  bone.  Divide  the  tendon  against  the 
bone.     Close  the  wound  as  described. 

Flexor  Carpi  Radialis, — Supinate  the  forearm, 
and  pass  the  tenotome  from  the  radial  artery  beneath 
the  tendon  from  without  inward. 

Flexor  Carpi  Ulnaris. — Supinate  the  forearm, 
and  pass  the  tenotome  beneath  the  tendon  from  with- 
out inward,  avoiding  the  ulnar  artery. 

The  extensors  of  the  wrist  need  no  special  men- 
tion. 

Biceps  Flexor  Cuhiti.  —  Supinate  the  forearm. 
Extend  the  elbow  to  locate  the  tendon. 

Pinch  up  the  integument  about  an  inch  above  the 
bend  of  the  elbow  over  the  tendon.  Pass  the  teno- 
tome fi'om  within  outward  beneath  the  tendon,  facili- 
tating its  passage  by  semiflexing  the  elbow. 

Extend  the  elbow,  and  divide  the  tendon  toward 
the  surface. 

After  the  inner  border  of  the  tendon  has  been 
exposed  in  this  operation,  it  is  better  to  use  a  probe- 
pointed  tenotome. 

Flexors  Longus  and  Brevis  Digitorum  and  Flexor 
Longus  Hallucis  may  be  divided  as  the  correspond- 
ing tendons  in  the  hand ;  also  the  extensor  proprius 
hallucis. 


70  OPERATIVE  SURGERY  OX  THE  CADAVER. 

Extensor  Longus  Dlgitorum  Pedis. — Place  tlie 
subject  on  tlie  back. 

Locate  tlie  tendon  by  extending  tlie  ankle.  Pass 
tlie  tenotome  beneath  the  tendon  from  witliin  out- 
ward about  an  inck  above  tke  bend  of  tke  ankle. 

Tibialis  Anticus, — Pass  tke  tenotome  from  with- 
out inward  beneath  tke  tendon  about  an  inck  above 
tke  ankle. 

By  adducting  tke  foot  and  flexing  tke  ankle,  tke 
passage  of  tke  tenotome  beneatk  tke  tendon  is  facili- 
tated. 

Tibialis  Posticus. — Place  tke  subject  on  tke  ab- 
domen. Stand  between  tke  legs.  Kotate  tke  leg 
inward,  and  flex  tke  ankle. 

Locate  tke  tendon  immediately  bekind  tke  in- 
ternal border  of  tke  tibia.  Draw  tke  integument 
backward  over  tke  tendon,  wkere  it  is  felt  about  an 
inck  above  tke  inner  malleolus.  Pierce  tke  tissues  to 
tke  tendon,  and  tken  witk  a  probe-pointed  tenotome 
divide  it  against  tke  tibia. 

Tke  tendon  is  made  taut  during  its  division  by 
abductino;  tke  foot  and  flexins^  tke  ankle. 

Peroneus  Longus  and  Brevis. — Witk  tke  subject 
lying  on  tke  abdomen,  stand  facing  tke  outside  of 
tke  leg. 

Draw  tke  integument  backward  over  tke  tendons, 
as  tkey  are  felt  just  posterior  to  tke  flbula  ^bout  an 
inck  above  tke  outer  malleolus.  Make  tke  tendons 
taut  by  adducting  tke  floot  and  flexing  tke  ankle.  Cut 
toward  tke  fibula. 

Tendo  Achillis. — Place  tke  subject  on  tke  abdo- 
men.    Stand  between  tke  legs. 

Pinck  up  a  fold  of  integument  over  tke  tendon. 


MANIPULATION  OF  TENOTOME.  71 

Introduce  the  tenotome  beneath  the  tendon  against 
its  anterior  surface  a  little  above  the  level  of  the  mal- 
leoli. Place  the  left  thumb  over  the  tendon,  which 
is  put  on  the  stretch  by  flexing  the  ankle.  Divide 
the  tendon,  takins;  care  that  the  tenotome  does  not 
cut  through  the  integument. 

Biceps  Femoris. — The  subject  on  the  abdomen, 
locate  the  tendon  w^ith  the  knee  extended. 

Push  the  tendon  outward  with  the  left  thumb. 
Enter  the  point  of  the  tenotome  about  two  inches 
above  the  head  of  the  fibula  to  the  inner  border  of 
the  tendon.  By  slightly  moving  the  point  of  the 
tenotome,  make  the  opening  in  the  fascia  larger. 
Pass  -a  probe-pointed  tenotome  internally,  and  then 
beneath  the  tendon,  the  knee  being  slighfcly  flexed. 
Care  must  be  taken  to  hug  the  tendon  to  avoid  the 
perineal  nerve.  Extend  the  knee  and  divide  the 
tendon. 

Semitendinosus  and  Semimemhranosus. — ^Locate 
the  tendons,  the  subject  being  placed  as  in  the  last 
operation.     Stand  on  the  outside  of  the  limb. 

Draw  the  interment  outward.  Enter  the  teno- 
tome  fi'om  without  inward  on  a  level  with  the  con- 
dyles of  the  femur.     Divide  the  tendons. 

The  semitendinosus  alone  may  be  divided,  or,  by 
advancing  the  blade  more  and  more  inward,  the  semi- 
membranosus and  other  internal  ham-string  muscles 
may  simultaneously  be  divided. 

Quadriceps  Extensor, — Place  the  subject  on  the 
back.     Stand  on  the  outside  of  the  limb. 

Draw  the  integument  above  the  patella  inward. 
Enter  the  tenotome,  or  preferably  a  fasciatome,  just 
external  to  the  tendon  above  the  patella,  and  advance 


72  OPEEATIYE  SURGERY  OR  THE  CADAVER. 

it  over  the  tendon.  Partially  divide  tlie  tendon,  cut- 
ting downward  until  tlie  deeper  fibers  can  be  rupt- 
ured. 

It  is  best  to  avoid  dividing  the  deeper  fibers  with 
the  knife,  lest  the  joint  be  opened. 

Adductor  Lo7igus. — Locate  the  tendon  just  below 
the  spine  of  the  pubes,  the  hip  being  abducted.  Draw 
the  integument  over  its  tendinous  origin  outward. 
Enter  the  tenotome  from  without  inward  beneath  the 
tendon.     Cut  upward  and  inward. 

From  the  foregoing  operations  it  may  be  noticed 
that,  when  cutting  in  the  proximity  of  important 
structures,  the  probe-pointed  tenotome  is  used  and 
passed  from  these  structures. 

Plantar  Fascia  (^Fasciatomy). — Pass  the  fascia- 
tome  from  within  outward  along  the  deeper  surface 
of  the  band  of  fascia  arising  from  the  inner  tuberosity 
of  the  OS  calcis.  Divide  the  fascia,  following  the 
same  rules  given  in  tenotomy. 

EXAMPLE    OF    TENDON    SUTUEINa. 

Sleeps  Femoris. — Make  an  incision  three  inches 
long  over  the  course  of  the  divided  tendon.  Expose 
the  ends  of  the  tendon,  and  cut  them  so  that  they 
will,  when  approximated,  present  oblique  surfaces  to 
each  other.  Securely  stitch  the  ends  together,  mak- 
ing the  sutures  extend  deeply  into  the  substance  of 
the  tendon.  The  hip  being  extended,  and  knee  flexed, 
the  divided  ends  of  the  tendon  are  easily  drawn  to- 
gether. 


CHAPTER  VIIL 

OPERATIONS     ON    NERVES    {NEUROTOMY,    NEURECTOMY, 
STRETCHING,  AND  SUTURING). 

KEUEOTOMY    OF    THE    LINGUAL. 

Sep  ABATE  the  jaws  by  means  of  a  gag. 

Introduce  the  left  index-finger  into  the  mouth, 
and  place  it  on  the  inner  surface  of  the  inferior  max- 
illa in  a  line  from  the  last  molar  tooth  to  the  angle. 
Introduce  a  curved  bistoury,  and  cut  the  tissues  an- 
terior to  the  finger. 

The  incision  should  be  an  inch  in  length,  and  par- 
allel to  the  line  in  which  the  finger  lies,  and  extend 
nearly  to  the  last  molar  tooth.  It  should  divide  all 
the  tissues  through  to  the  bone.  The  finger  acts 
as  a  guide. 

NEUEECTOMY    OF    THE    SPIl^AL    ACCESSOEY. 

Place  the  subject  on  the  back,  and  turn  the  head 
away  from  the  side  of  the  operation. 

Make  an  incision  three  inches  long  just  external 
to  the  anterior  border  of  the  sterno-cleido-mastoid  mus- 
cle, with  its  middle  point  on  a  level  with  the  angle 
of  the  jaw.  Divide  the  integument  and  fasciae,  and 
open  into  the  sheath  of  the  sterno-cleido-mastoid  mus- 
cle. Retract  the  sides  of  the  wound.  Divide  the 
muscular  fibers  in  the  middle  of  the  wound  on  a  di- 


T4  OPERATIVE  SURGERY  ON  THE  CADAVER. 

rector  until  tlie  nerve  is  exposed.     Excise  an  inch  or 
more  of  tlie  nerve. 

The  nerve  is  sometimes  found  between  the  sternal 
and  clavicular  fibers,  but  generally  beneath  this  sep- 
tum. Sometimes  the  nerve  is  beneath  the  whole 
muscle.  By  searching  the  posterior  border  of  the 
muscle,  the  nerve  can  be  found  and  followed  back 
into  the  muscle.  Provide  drainage,  and  close  the 
wound. 

]S^EEVE-STIlETCHINa    OF    THE    GREAT    SCIATIC. 

Place  the  subject  on  the  abdomen. 

Begin  an  incision  a  little  above  the  gluteal  fold, 
and  extend  it  downward  four  inches  in  the  middle 
line  of  the  thigh.  Divide  the  integument  and  fasciae, 
and  expose  the  border  of  the  gluteus-maximus  muscle. 
Divide  the  cellular  tissue  along  the  outer  border  of 
the  long  head  of  the  biceps  femoris,  and  retract  the 
sides  of  the  wound.  The  nerve  is  seen  resting  on  the 
adductor  magnus.  Separate  the  nerve  with  the  fin- 
gers. Raise  the  leg  from  the  table  by  pulling  on  the 
nerve  hooked  up  by  the  fingers.  If  the  limb  is  very 
heavy,  it  need  not  be  quite  raised.  Provide  for  drain- 
age, and  close  the  wound. 

JSTERVE-SUTUEIKG    OF    THE    MEDIATE. 

Supinate  the  forearm. 

Begin  an  incision  about  two  inches  above  the 
wrist,  between  the  tendons  of  the  palmaris  longus 
and  the  flexor  carpi  radialis.  The  incision  should 
extend  upward  three  inches,  dividing  the  integument 
and  fasciae.  Separate  the  tendons  of  the  palmaris 
longus  and  the  flexor  carpi  radialis,  and  raise  the 


OPERATIONS  ON  NERVES.  75 

flexor  sublimis  digitorum  muscle.  Retract  the  sides 
of  the  wound  to  expose  the  nerve.  (Excise  an  inch 
of  the  nerve.) 

Both  ends  of  the  nerve  being  exposed,  should  be 
stretched  by  means  of  forceps  to  approximate  them. 
Freshen  the  ends  of  the  nerve  by  cutting  away  the 
tips  which  were  crushed  by  the  forceps.  Bring  the 
ends  into  apposition  by  means  of  stitches  extending 
through  the  nerve-sheath  only.  Provide  for  drain- 
age, and  close  the  wound. 


CHAPTER  IX. 

OPERATIONS  ON  THE  CIRCULATORY  SYSTEM. 
COMPRESSIOIS^    OF   VESSELS. 

1.  Peessuee  is  applied  to  a  particular  vessel  by 
various  means,  of  whicli  Pet  it's  tourniquet  will  be 
considered. 

Apply  tlie  tourniquet  by  encircling  the  limb  witli 
tlie  strap,  placing  under  the  strap  and  over  the  vessel 
a  compress.  A  roller-bandage  will  act  as  a  compress, 
and  should  be  placed  so  as  to  engage  the  vessel  be- 
tween it  and  the  bone.  The  lumen  of  the  vessel  is 
closed  by  turning  the  screw  of  the  tourniquet  to 
tighten  the  strap. 

2.  The  soft  tissues  of  a  part  may  be  compressed 
by  various  means,  of  which  the  elastic  bandage  and 
tubino;  are  in  most  common  use. 

Apply  the  bandage  spirally,  overlapping  each 
turn  to  a  very  slight  extent.  The  bandage  must  be 
stretched  before  the  turn  is  applied. 

If  a  limb  is  to  be  rendered  bloodless,  apply  the 
bandage  from  the  extremity  toward  the  trunk.  The 
last  two  or  three  turns  of  the  bandage  may  be  tied 
together,  and  the  bandage  removed  from  below,  or 
the  limb  may  be  encircled  by  rubber  tubing  just 
above  the  bandage,  when  the  bandage  may  be  entirely 
removed. 


OPERATIONS  ON  THE  CIRCULATORY  SYSTEM.     "11 

At  tlie  slioulder  tlie  tubino:  must  run  under  the 
axilla  and  over  the  clavicle. 

At  the  groin  the  tubing  must  run  between  the 
anus  and  the  tuber  ischii  of  the  side  to  be  compressed, 
and  over  the  middle  of  the  crest  of  the  ilium.  It  can 
be  held  above  the  ilium  or  secured  to  a  belt  or  band- 
age encircling  the  body  just  above  the  crests  of  the 
ilia. 

The  tubing,  like  the  bandage,  must  be  stretched 
before  the  turns  are  applied  to  the  part. 

TOESIOI^    OF   VESSELS. 

A  vessel  of  considerable  size  must  be  seized  at 
its  end  by  means  of  forceps  and  separated  from 
the  surrounding  tissue  to  an  extent  to  allow  of  be- 
ing seized  at  a  right  angle  to  its  course  by  a  second 
pair  of  forceps.  A  quarter  of  an  inch  of  the  vessel 
should  separate  the  forceps  if  the  vessel  is  of  large 
size.  Turn  the  force23s  holding  the  end  of  the  vessel 
until  but  slight  resistance  is  offered,  after  which  the 
other  pair  of  forceps  are  removed.  The  forceps  hold- 
ing the  end  of  the  vessel  is  last  removed.  On  the 
cadaver  the  effect  of  the  torsion  can  only  be  surmised. 

Vessels  of  small  size  are  caught  by  means  of  for- 
ceps, and  twisted  until  their  ends  (and  the  little  tis. 
sue  always  included  in  the  bite  of  the  forceps)  sep- 
arate fi^om  the  cut  surface. 

LiaATUEE    OF   VESSELS. 

I.  Ligature  of  a  Divided  Vessel. — Ligature  of  a 
severed  vessel  is  performed  by  catching  the  end  of 
the  vessel  by  means  of  forceps,  and  then  compressing 
the  vessel  in  the  loop  of  a  knot. 


78  OPERATIVE  SURGERY  ON-  THE  CADAVER. 

If  the  vessel  is  large,  it  sliould  be  separated  from 
surrounding  tissues,  and  accurately  ligatured. 

When  catgut  is  used,  a  tHrd  knot  should  be  tied 
to  insure  against  the  loosening  of  the  ligature. 

If  the  vessel  is  of  small  size,  some  of  the  sur- 
rounding tissue  is  included  in  the  loop  of  the  knot. 

Care  must  be  exercised  to  prevent  including  the 
instrument  in  the  loop  of  the  knot.  A  tenaculum 
may  be  used  to  pick  up  the  vessel  and  adjacent  tis- 
sue, ^vhen,  if  the  tissue  is  nicked  for  the  ligature,  it 
is  not  liable  to  slip. 

The  first  knot  should  be  drawn  upon  until,  in  the 
case  of  a  large  vessel,  its  inner  coats  are  felt  to  crush. 
The  second  knot  should  never  be  drawn  upon  with 
great  force,  for  the  ligature  is  then  very  readily 
broken. 

If  a  vessel  is  cut,  but  not  severed,  and  the  vessel 
be  a  large  vein,  the  opening  is  pinched  together  by 
means  of  forceps,  and  the  ligature  applied  as  for  a 
small  vessel.  The  caliber  of  the  vein  is  thus  not  oc- 
cluded. In  case  of  arteries,  the  section  must  be  com- 
pleted, and  both  ends  treated  with  a  ligature.  On 
the  cadaver  a  partially  severed  vessel  is  hardly  no- 
ticed. 

II.  Ligature  of  a  Vessel  in  its  Continuity. — The 
position  of  a  vessel  is  determined  by  certain  ^^  guides  "  : 

1.  The  surface  guide  is  a  line  drawn  Joining  cer- 
tain fixed  points,  as  bony  eminences. 

2.  The  deep  guides  are  the  contiguous  anatomical 
structures. 

3.  The  feel  and  color  of  the  vessel. 

General  Rules. — When  the  location  is  chosen,  the 
incision   is  made  usually  in   the  surface  guide,  its 


OPERATIONS  ON  THE  CIRCULATORY  SYSTEM.     79 

lengtli  being  determined  by  tlie  depth  of  tlie  vessel 
from  tlie  surface.  The  central  point  of  this  incision 
should  correspond  as  nearly  as  possible  to  the  part  of 
the  vessel  to  be  included  in  the  ligature.  All  the 
tissues  must  be  divided  to  the  same  extent,  important 
structures  being  pushed  aside.  As  the  vessel  is  ap- 
proached, the  tissues  may  be  divided  on  a  director. 

When  the  sheath  or  areolar  tissue  contiguous  to 
the  vessel  is  reached,  it  is  picked  up  by  forceps  and 
nicked ;  a  director  is  introduced  through  the  opening, 
and  the  tissue  divided  for  a  quarter  of  an  inch.  If 
the  vessel  is  still  enveloped  in  tissue,  an  opening  is 
made  into  it  as  just  described.  Catch  the  edge  of 
the  wound  in  the  sheath  on  the  side  toward  the  vein 
or  other  important  structure  by  means  of  forceps. 
Roll,  by  means  of  a  probe  or  director,  the  vessel  away 
from  the  sheath  thus  securely  fixed.  The  probe  or 
director  should  be  held  at  a  right  angle  to  the  vessel, 
and  be  moved  between  the  vessel  and  the  sheath  to 
an  extent  less  than  the  opening  in  the  sheath.  It 
may  be  necessary  to  catch  the  opposite  edge  of  the 
wound  in  the  sheath  to  separate  the  vessel  completely 
around  its  whole  circumference. 

An  aneurism-needle  carrying  a  ligature  is  passed 
under  the  vessel  from  the  side  on  which  the  most 
vulnerable  structure  is  situated.  The  sheath  should 
be  cauo^ht  first  on  the  side  of  the  introduction  of  the 
needle  by  means  of  forceps,  and  then  again  on  the 
side  of  exit,  to  make  way  for  the  point  of  the  needle. 
If  the  vessel  is  deeply  situated,  the  point  of  the 
needle  is  caught  after  it  has  passed  beneath  the  ves- 
sel, and  the  handle  of  the  instrument  is  unscrewed  to 
allow  the  curved  end  of  the  needle  carrying  the  liga- 


80  OPERATIVE  SURGEEY  ON  THE  CADAVER. 

ture  to  be  drawn  under  tlie  vessel.  One  end  of  tlie 
ligatui'e  is  held  to  prevent  tlie  whole  ligature  being 
drawn  under  the  vessel. 

The  ligature  being  under  the  vessel,  the  first  loop 
of  the  knot  is  applied  at  a  right  angle  to  the  course 
of  the  vessel.  Draw  upon  the  knot  by  means  of  the 
fingers,  which  must  press  upon  the  ends  of  the  liga- 
ture close  to  the  vessel.  The  second  knot  is  not  to  be 
drawn  upon  very  forcibly.  Do  not  allow  the  tight- 
enino;  of  the  knots  to  raise  the  vessel  from  its  bed. 

(Prove  the  operation  by  opening  into  the  vessel 
to  discover  the  thickness  of  its  walls,  etc.) 

LIGATURE    OF    SPECIAL   AETEEIES    IN   THEIE  CONTINUITY. 

Radial  Artery. — Supinate  the  forearm  and  ex- 
tend the  wrist. 

The  surface  guide  is  a  line  drawn  from  a  point 
midway  between  the  tips  of  the  condyles  of  the 
humerus  to  a  point  about  one  half  of  an  inch  internal 
to  the  tip  of  the  styloid  process  of  the  radius. 

1.  Lower  Third. — Make  an  incision  two  inches 
long  in  the  line  of  the  artery,  extending  to  within 
one  inch  of  the  wrist.  Divide  the  integument  and 
superficial  fascia.  Push  aside  any  veins  which  ap- 
pear, and  divide  on  a  director  the  deep  fascia.  Ex- 
pose the  artery  between  the  tendons  of  the  flexor  carpi 
radialis  and  supinator  longus.  Nick  the  areolar  tissue 
enveloping  the  artery,  and  pass  the  needle,  avoiding 
the  vense  comites.  Ligate  the  vessel.  Close  the 
wound,  providing  for  drainage. 

2.  Middle  Third. — Divide  the  integument  and 
fascia  in  the  line  of  the  artery.  Look  for  the  inner 
edge  of  the  supinator  longus,  which  is  near  the  mid- 


OPERATION'S  ON  THE   CIRCULATORY  SYSTEM.     81 

die  line  of  tlie  forearm.  Retract  the  supinator  Ion- 
gus  outward  to  uncover  tlie  artery.  Pass  tlie  needle 
from  without  inward,  to  avoid  the  radial  nerve. 

The  radial  artery  may  lie  on  the  deep  fascia,  or 
on  the  supinator  longus  muscle. 

Ulis^ae  Aeteey. — Supinate  the  forearm  and  ex- 
tend the  wrist. 

The  surface  guide  to  the  vessel,  for  the  lower  two 
thirds  of  its  course,  is  a  line  drawn  from  the  internal 
condyle  of  the  humerus  to  the  radial  side  of  the  pisi- 
form bone. 

1.  Lower  Third. — Make  an  incision  three  inches 
long  in  the  line  of  the  artery,  extending  to  within 
one  inch  of  the  wrist.  Divide  the  integument  and 
superficial  fascia.  Push  aside  any  veins  which  may 
be  present,  and  divide  the  deep  fascia  on  a  director. 
Flex  the  wrist  and  retract  the  flexor  carpi  ulnaris 
muscle  toward  the  ulnar  side  to  uncover  the  artery. 
Pass  the  needle  from  within  outward,  to  avoid  the 
ulnar  nerve. 

2.  Middle  Third. — Make  an  incision  three  inches 
long  in  the  line  of  the  vessel.  Find  the  interspace 
between  the  flexor  carpi  ulnaris  and  the  flexor  sub- 
limis  digitorum.  Avoid  mistaking  the  pal  maris  lon- 
gus or  the  supinator  longus  for  the  flexor  sublimis 
digitorum.  Separate  the  muscles  and  retract  the 
sides  of  the  wound.  Pass  the  needle  from  within 
outward. 

The  artery  may  lie  superficial  to  the  muscles  or 
deep  fascia. 

Beachial  Aeteey. — Abduct  the  arm  and  rotate 
it  outward,  also  supurate  the  forearm. 

The  surface  guide  is  a  line  drawn  from  the  June- 


82  OPERATIVE  SURGERY  ON  THE  CADAVER. 

tion  of  the  anterior  and  middle  thirds  of  the  axilla  to 
a  point  midway  between  the  condyles  of  the  humerus. 

1.  JB end  of  Elbow. — Make  an  incision  two  inches 
long  in  the  line  of  the  artery,  at  the  bend  of  the  elbow. 
Divide  the  integument  and  superficial  fascia,  pushing 
aside  the  median  basilic  vein.  Divide  on  a  director 
the  deep  fascia  and  the  bicipital  fascia.  Slightly  flex 
the  elbow.  Find  the  artery  with  the  bicipital  tendon 
situated  externally  and  the  median  nerve  internally. 
Pass  the  needle  from  within  outward. 

2.  Lower  Half  of  the  Arm, — Make  an  incision 
three  inches  long  in  the  line  of  the  artery,  dividing 
the  integument  and  superficial  fascia.  Divide  the 
deep  fascia  internal  to  the  biceps  muscle.  Slightly 
flex  the  elbow,  and  retract  the  biceps  muscle  outward. 
Find  the  artery  with  the  median  nerve  situated  above, 
which  is  to  be  retracted  outward  with  the  muscle. 

Pass  the  needle  from  within  outward,  avoiding 
the  veins. 

3.  Upper  Arm. — Make  an  incision  three  inches 
long  in  the  line  of  the  artery,  dividing  the  integu- 
ment and  superficial  fascia.  Divide  the  deep  fascia 
internal  to  the  coraco-brachialis  muscle.  Ketract 
outward  the  coraco-brachialis  muscle,  and  find  the  ar- 
tery with  the  median  nerve  situated  above  and  exter- 
nally, and  the  ulnar  nerve  internally. 

Retract  the  median  nerve  outward,  and  the  basilic 
vein  and  ulnar  nerve  inward.  Pass  the  needle  from 
within  outward. 

The  brachial  artery  may  divide  high  in  its  course 
or  run  superficially  to  the  median  nerve,  etc. 

AxiLLAEY  Artery  (fldrd  portiori). — Abduct  and 
rotate  outward  the  arm. 


OPERATIONS  OJSr  THE  CIRCULATOEY  SYSTEM.     83 

The  surface  guide  to  the  portion  of  the  artery  for 
ligation  is  a  line  drawn  between  the  anterior  and 
middle  thirds  of  the  axilla. 

Make  an  incision  three  inches  Ions;  in  the  line  of 
the  artery,  extending  an  inch  above  the  anterior  fold 
of  the  axilla.  Divide  the  integument  and  superficial 
fascia.  Divide  the  deep  fascia  along  the  internal  bor- 
der of  the  coraco-brachialis  muscle,  and  retract  this 
muscle  outward.  Find  the  artery  with  the  median 
and  the  musculo-cutaneous  nerves  situated  externally 
and  the  ulnar  and  the  internal  cutaneous  nerves  in- 
ternally. The  axillary  vein  is  posterior  and  situated 
more  superficially.  Pass  the  needle  from  within  out- 
ward. 

SuBCL AVIATE  Arteey  (s€cond  and  third  portions), 
— Place  a  small  block  under  the  back  of  the  subject. 
Turn  the  face  to  the  opposite  side  and  draw  down- 
ward the  shoulder. 

The  surface  guide  is  a  line  four  inches  long,  drawn 
one  half  inch  above  and  parallel  to  the  clavicle.  The 
line  should  be  drawn  outward  from  a  ^omi  two 
inches  external  to  the  sternal  end  of  the  clavicle. 

Stand  behind  the  shoulder.  Draw  the  integu- 
ment downward,  and  incise  it  against  the  clavicle. 
Allow  the  integument  to  retract  so  as  to  bring  the 
incision  above  the  clavicle.  Divide  the  superficial 
fascia  and  platysma,  pushing  aside  the  external  jugu- 
lar vein.  Partially  sever  the  sterno-cleido-mastoid 
and  trapezius  muscles  if  necessary.  Tease  a  way 
through  the  areolar  tissue  with  its  plexus  of  veins 
formed  by  the  supra-scapular  and  transverse  cervical 
veins  until  the  omo-hyoid  muscle  is  uncovered.  Di- 
vide on  a  director  the  deep  fascia,  and  retract  the 


84  OPERATIVE  SURGERY  ON'  THE  CADAVER. 

omo-]iyoid  muscle  upward.  Feel  tlie  taut  scalenus 
anticus  muscle,  and  follow  its  outer  border  downward 
to  the  tubercle  of  the  first  rib.  The  artery  is  situated 
immediately  behind  the  muscle,  as  it  is  inserted  into 
this  tubercle, 

Tease  the  tissues  from  the  vessel.  The  cords  of 
the  brachial  plexus  and  the  omo-hyoid  muscle  are  to 
be  retracted  backward.  The  subclavian  vein  is  not 
seen,  as  it  lies  in  front  of  the  scalenus  anticus  mus- 
cle and  at  a  lower  level.  Pass  the  needle  from  before 
backward. 

If  the  second  portion  is  to  be  ligated,  divide  the 
scalenus  anticus  muscle,  guarding  against  injuring  the 
phrenic  nerve  or  transversus  colli  artery.  On  the 
left  side  the  thoracic  duct  also  lies  on  the  scalenus 
anticus  muscle.  Hug  the  artery  with  the  needle  to 
avoid  the  pleura. 

Sometimes  the  vein  and  artery  change  situations ; 
also,  large  branches  given  off  from  the  artery  may 
complicate  the  operation. 

Vertebral  ArteIry. — Place  the  subject  on  the 
back,  and  turn  the  face  to  the  opposite  side. 

The  surface  guide  is  the  depression  between  the 
posterior  border  of  the  sterno-cleido-mastoid  and  the 
scalenus  anticus  muscles. 

Make  an  incision  four  inches  long,  following  the 
posterior  border  of  the  sterno-mastoid  muscle  down- 
ward to  within  one  half  inch  of  the  clavicle.  Divide 
the  integument,  platysma,  and  superficial  fascia,  and 
retract  inward  the  external  jugular  vein.  Separate 
the  sterno-cleido-mastoid  muscle  from  the  scalenus 
anticus  muscle.  The  muscle  must  be  relaxed,  by 
turning  the  face  of  the  subject  forward.    The  phrenic 


OPERATIONS  ON  THE  CIRCULATORY  SYSTEM.     85 

nerve,  trans versalis  colli  artery,  and  on  tlie  left  side 
tlie  thoracic  duct,  may  be  seen  on  the  surface  of  the 
scalenus  anticus.  Avoid  wounding  these  structures, 
and  separate  the  scalenus  anticus  from  the  longus 
colli  muscle.  In  the  interspace  betv^een  these  mus- 
cles, the  vertebral  vein  will  first  be  uncovered.  In 
the  lower  angle  of  the  wound  the  pleura  is  uncov- 
ered. Retract  the  vein  and  pass  the  needle  from  the 
vein  before  backward,  being  mindful  of  the  proxim- 
ity to  the  pleura,  and  of  the  thoracic  duct  crossing 
from  mthin  outward. 

The  vertebral  vessels  vary  in  regard  to  which 
.  foramen  in  the  transverse  processes  of  the  cervical 
vertebrae  they  enter.  The  arteries  vary  often  in  their 
origin,  and  hence  in  their  manner  of  reaching  the  in- 
termuscular space  between  the  longus  colli  and  sca- 
lenus anticus  muscle. 

Common  Carotid  Aeteey. — Place  the  subject  on 
the  back,  with  a  block  between  the  shoulders^  and 
turn  the  face  to  the  opposite  side. 

The  surface  guide  is  included  in  a  line  drawn 
from  a  point  midway  between  the  angle  of  ihe  jaw 
and  the  mastoid  process,  to  a  point  over  the  sterno- 
clavicular articulation.  That  portion  of  the  line  be- 
low the  level  of  the  superior  border  of  the  thyroid 
cartilage  is  the  surface  guide. 

Stand  behind  the  shoulder. 

1.  Ligature  over  the  Carotid  Tubercle. — Make  an 
incision  four  inches  long  in  the  line  of  the  artery,  be- 
ginning one  half  inch  above  the  clavicle.  Divide 
the  integument,  platysma,  and  superficial  fascia.  Re- 
tract the  edo-es  of  the  wound  and  divide  the  fascia 
at  the  anterior  border  of  the  sterno-mastoid  muscle. 


86  OPEEATIVE  SURGERY  ON  TEE   CADAVER. 

Separate  tlie  muscle  by  means  of  the  fingers  from  its 
attachments.  Divide  the  fibers  near  the  sternal  ori- 
gin with  a  probe-pointed  bistourj^,  gnided  on  the  left 
index-finger.  Raise  the  head,  to  allow  the  muscle  to 
be  retracted  outward.  Push  aside  or  divide  between 
ligatures  the  anterior  jugular  vein.  Divide  the  fas- 
cia on  a  director,  at  the  outer  border  of  the  sterno- 
hyoid muscle,  and  retract  the  sterno-hyoid  and  sterno- 
thyroid muscles  inward. 

Feel  for  the  carotid  tubercle  (the  anterior  tuber- 
cle of  the  transverse  process  of  the  sixth  cervical  ver- 
tebra) about  two  inches  above  the  clavicle.  The 
artery  is  readily  felt  lying  upon  this  tubercle.  Ex- 
pose the  carotid  sheath,  avoiding  the  recurrent  laryn- 
geal nerve  and  the  inferior  thyroid  artery  internally, 
and  remembering  that  the  left  internal  jugular  may 
lie  over  the  artery  in  this  location.  Open  the  sheath 
through  its  inner  side  directly  over  the  artery.  The 
pneumogastric  nerve  is  situated  behind  and  exter- 
nally, and  the  internal  jugular  vein  in  front  and 
externally,  hence  the  needle  is  passed  from  without 
inward. 

2.  Ligature  at  the  Level  of  tlie  Cricoid  Cartilage, — 
Make  an  incision  about  four  inches  long  in  the  line 
of  the  artery,  having  its  central  point  at  the  level  of 
the  cricoid  cartilage.  Divide  the  integument,  platys- 
ma,  and  superficial  fascia.  Divide  the  fascia  at  the 
anterior  border  of  the  sterno-mastoid  muscle,  and 
retract  the  muscle  outward.  The  sterno-mastoid  ar- 
tery may  be  seen  divided.  Avoid  the  middle  thyroid 
vein  or  divide  it  between  ligatures.  In  the  upper 
angle  of  the  wound  avoid  injuring  the  superior  thy- 
roid, lingual,  and  facial  veins,  and  in  the  lower  an- 


OTEEATIONS  ON  THE  GIEGULATORT  SYSTEM.     87 

gie  tlie  anterior  jugular  vein.  Divide  the  deep  fascia 
on  a  director,  and  retract  inward  tlie  sterno-tliyroid 
and  sterno-liyoid  muscles. 

The  omo-hyoid  muscle  is  known  by  its  fibers  ex- 
tending across  the  carotid  sheath  upward  and  inward. 
Oil  the  inner  side  of  the  sheath  the  descendens  noni 
nerve  is  seen.  The  omo-hyoid  muscle  is  retracted 
upward  or  downward,  or  may  be  divided.  Open  the 
carotid  sheath  on  its  inner  aspect,  avoiding  the  de- 
scendens noni  nerve.  Pass  the  needle  from  without 
inward,  avoiding  the  internal  jugular  vein  and  the 
pneumogastric  nerve. 

If  the  artery  be  ligated  above  the  level  of  the 
cricoid  cartilage,  the  superior  thyroid  artery  must  be 
avoided.  If  the  ligature  is  placed  below  the  level 
of  the  cricoid  cartilage,  remember  that  the  recurrent 
laryngeal  nerve  and  the  inferior  thyroid  artery  are 
located  behind  and  internally. 

The  artery  may  bifurcate  at  a  lower  level  than 
the  upper  border  of  the  thyroid  cartilage.  The  omo- 
hyoid muscle  may  cross  the  artery  at  a  different  level. 
The  artery  may  give  off  branches,  usually  arising 
from  the  external  carotid. 

Interjn^al  Caeotid  Aeteey. — Place  the  subject 
as  in  the  last  operation. 

The  surface  guide  is  the  portion  of  tlie  previously 
dra^vn  line,  extending  from  the  level  of  the  upper 
border  of  the  th^^roid  cartilage  to  the  point  midway 
between  the  angle  of  tlie  jaw  and  the  mastoid  pro- 
cess. Begin  an  incision  at  the  upper  extremity  of 
this  line,  and  continue  it  downward,  following  the 
line  to  the  level  of  the  body  of  the  thyroid  cartilage. 

Divide  the  integument,  platysma,  and  superficial  fascia. 

7 


88  OPERATIVE  SURGERY  ON  TEE  CADAVER. 

Divide  tlie  fascia  at  tlie  anterior  border  of  the  sterno- 
mastoid  muscle,  and  retract  the  muscle  outward,  rais- 
ing the  head  slightly  to  relax  the  muscle.  Avoid 
the  facial,  lingual,  and  inferior  thyroid  veins.  Divide 
the  deep  fascia  on  a  director,  and  retract  upward  and 
inward  the  posterior  belly  of  the  digastric  and  the 
stylo-hyoid  muscles.  The  external  carotid  crossed  by 
the  hypoglossal  nerve  is  now  exposed  and  must  be 
retracted  inward.  The  internal  carotid  can  be  felt 
posterior  and  external  to  the  external  carotid. 

Apply  the  ligature  about  one  inch  above  the 
origin  of  the  artery,  passing  the  needle  from  without 
inward,  to  avoid  the  internal  jugular  vein  and  the 
pneumogastric  nerve. 

The  artery  may  begin  at  different  levels.  The  ar- 
tery may  be  situated  internal  to  the  external  carotid. 

ExTERi^AL  Caeotid  Aeteey. — Place  the  subject 
as  in  the  previous  operation.  Expose  the  artery  as 
described.  Ligate  the  vessel  fully  an  inch  above  the 
bifurcation  of  the  common  carotid.  Pass  the  needle 
from  without  inward.  Before  tightening  the  ligature 
find  a  branch  given  off  from  the  vessel,  to  eliminate 
the  internal  carotid.  Tie  anv  branches  o-iven  off  near 
the  location  of  the  ligature. 

SuPEEioE  Thyroid  Aeteey. — The  subject  is 
placed  as  in  the  previous  operations. 

Make  an  incision  nearly  three  inches  long,  fol- 
lowing the  anterior  border  of  the  sterno-mastoid 
muscle,  and  having  its  middle  point  on  a  level  with 
the  upper  border  of  the  thyroid  cartilage.  Divide 
the  integument,  platysma,  and  superficial  fascia.  Di- 
vide the  fascia  along  the  anterior  border  of  the  sterno- 
mastoid  muscle.    Ketract  outward  the  sterno-mastoid 


OPERATIONS  OF  TEE  CIRCULATORY  SYSTEM.     89 

muscle  to  expose  tlie  artery  crossing  the  floor  of  tlie 
superior  carotid  triangle  between  tlie  common  carotid 
artery  and  tlie  lobe  of  the  thyroid  gland.  Avoid 
the  lingual,  facial,  and  superior  thyroid  veins.  Pass 
the  needle,  directing  its  point  toward  the  lobe  of  the 
thyroid  gland. 

Lus-GUAL  Aetery.— Turn  the  face  of  the  subject 
away  from  the  side  of  the  operation,  and  draw  the 
chin  upward. 

Make  an  incision  about  three  inches  long,  follow- 
ing the  superior  border  of  the  hyoid  bone.     This 
incision  should  be  slightly  concave  superiorly,  and 
should  begin  at  a  point  one  half  inch  external  to  the 
median  line.     Divide  the  integument,  platysma,  and 
superficial  fascia.     Separate  the  fascia  from  the  lower 
part  of  the  submaxillary  gland,  and  hook  the  gland 
upward.     The  hypoglossal  nerve,  making  a  triangle 
mth  the  looped  tendon  of  the  digastric  muscle,  is 
seen  in  the  bottom  of  the  wound.     The  lingual  vein 
generally  lies  upon  the  floor  of  this  triangle,  follow- 
ing the  hypoglossal  nerve.     Divide  on  a  director  the 
fibers  of  the  hyoglossus  muscle  just  above  the  looped 
tendon  of  the  digastic  muscle.     The  lingual  artery 
may  be  encountered  in  the  fibers  of  the  muscle,  or 
will  be  seen  running  horizontally  beneath  the  muscle. 
If  the  lino-ual  vein  should  be  found  in  company 
with  the  artery,  pass  the  needle  from  the  vein. 

Facial  AetepwY. — Turn  the  face  of  the  subject 
away  from  the  side  of  the  operation. 

Draw  the  skin  upward  over  the  ramus  of  the  jaw. 
Make  an  incision  two  inches  long,  following  the  lower 
border  of  the  bone.  A  point  over  the  junction  of 
the  posterior  with  the  middle  third  of  the  body  of  the 


90  OPERATIVE  SURGERY  OF  THE  CADAVER. 

bone  should  mark  the  middle  of  the  incision.  Divide 
the  integument,  platysma,  and  superficial  fascia,  being 
careful  not  to  bear  upon  the  knife  as  it  crosses  the 
artery.  The  fascia  had  better  be  divided  on  a  di- 
rector. Ketract  the  sides  of  the  incision,  when  the 
artery  can  be  found  crossing  the  ramus  of  the  jaw  at 
the  lower  part  of  the  anterior  border  of  the  masseter 
muscle. 

Pass  the  needle  from  behind  forward,  to  avoid 
the  facial  vein. 

Occipital  Aeteey. — Turn  the  face  of  the  subject 
away  from  the  side  of  the  operation ;  shave  the  part. 

Begin  an  incision  posteriorly  to  and  a  little  below 
the  apex  of  the  mastoid  process,  and  continue  it  three 
inches  in  the  direction  of  the  external  occipital  pro- 
tuberance. Divide  the  integument  and  fascia.  Di- 
vide the  stemo-mastoid  and  splenius  muscles  to  the 
extent  of  the  wound.  Retract  the  edges  of  the 
wound,  when  the  tortuous  artery  will  be  seen. 

Tempoeal  Aeteey. — ^Turn  the  face  of  the  subject 
away  from  the  side  of  the  operation. 

Make  an  incision  about  two  inches  long  at  a  right 
angle  to  the  zygoma,  having  its  middle  point  just  in 
front  of  the  tragus,  between  the  tragus  and  the  root 
of  the  zygoma. 

Divide  the  integument  and  superficial  fascia,  when 
the  artery  can  be  felt  surrounded  by  dense  fascia. 
Divide  on  a  director  the  fascia  over  the  artery,  and 
pass  the  needle  from  behind  forward,  to  avoid  the 
temporal  vein  and  the  auriculo-temporal  nerve. 

Common  Iliac  Aeteey. — Place  the  subject  on 
the  back,  inclined  somewhat  to  the  opposite  side. 

The  surface  guide  to  the  common  and  external 


OPERATION'S  ON  THE  CIRCULATORY  SYSTEM.     91 

iliac  arteries  is  a  line  drawn  from  a  point  a  little  to 
the  left  of  tlie  umbilicus  to  a  point  midway  between 
the  symphysis  pubis  and  the  anterior  superior  spinous 
process  of  the  ilium.  The  upper  limit  of  this  line 
may  also  be  determined  by  taking  a  point  an  inch  to 
the  left  of  the  middle  point  of  a  line  drawn  from  the 
highest  portion  of  one  iliac  crest  to  that  of  the  other. 
The  upper  two  or  three  inches  of  this  line  correspond 
to  the  course  of  the  vessel. 

Make  an  incision  concave  internally  from  the 
cartilage  of  the  eleventh  rib  to  a  point  two  inches 
above  the  middle  of  Poupart's  ligament.  Divide 
the  integument  and  fascia,  the  external  oblique  apo- 
neurosis, the  internal  oblique,  and  the  transversalis 
muscles.  Divide  the  transversalis  fascia  on  a  director 
to  the  full  extent  of  the  wound.  With  the  finsrers 
separate  the  peritonaeum  and  subserous  areolar  tissue 
from  the  iliac  fossa  until  the  psoas  muscle  covered 
by  the  psoas  fascia  is  seen.  Along  the  inner  border 
of  this  muscle,  above  the  level  of  the  sacro-iliac  syn- 
chondrosis, the  artery  can  be  felt. 

On  the  left  side  the  superior  haemorrhoidal  ves- 
sels and  the  attachment  of  the  sigmoid  mesocolon 
must  be  pushed  aside,  and  the  needle  passed  from 
within  outward. 

On  the  right  side  pass  the  needle  from  without 
inward,  to  avoid  the  iliac  veins  which  have  crossed 
under  the  artery  to  form  the  vena  cava. 

The  ureter  generally  adheres  to  the  tissues  raised, 
but,  if  found  crossing  the  lower  part  of  the  artery, 
it  may  be  retracted  downward. 

The  arteries  vary  in  length,  and  may  give  off 
branches. 


92  OPERATIVE  SURGERY  OJ^  TEE  CADAVER. 

Internal  Iliac  Artery. — The  operation  is  the 
same  as  that  to  expose  the  common  iliac.  The  artery 
can  be  felt  as  it  runs  down  into  the  pelvis  over  the 
sacro-iliac  synchondrosis  at  the  inner  side  of  the  psoas 
muscle.  The  needle  should  be  passed  nearly  an  inch 
below  the  origin  of  the  artery  from  within  outward 
and  from  behind  forward.  Special  precautions  are 
to  be  taken  to  avoid  the  external  iliac  vein  and  the 
ureter  in  front.  The  needle  should  have  its  curve 
set  at  a  right  angle  to  the  shaft,  and  should  be  made 
for  right  and  left  arteries. 

The  common  and  internal  iliacs  may  be  more  con- 
veniently ligated  by  performing  a  median  laparotomy, 
retracting  or  removing  from  the  abdominal  cavity  the 
intestines,  incising  the  posterior  wall  of  the  perito- 
naeum, and  by  passing  the  ligature  as  already  de- 
scribed. 

Gluteal  Artery. — Place  the  subject  on  the  belly, 
and  rotate  the  hip-joint  inward. 

The  surface  guide  is  a  line  drawn  from  the  pos- 
terior superior  spinous  process  of  the  ilium  to  the 
middle  of  the  trochanter  major.  At  the  junction  of 
the  upper  and  middle  thirds  of  this  line  the  artery 
emerges  from  the  pelvis. 

Begin  an  incision  about  an  inch  from  the  upper 
limit  of  this  line,  and  extend  it  downward  ^ve  inches, 
following  the  line.  Divide  the  integument  and  fascia, 
separate  the  fibers  of  the  gluteus  maximus  muscle,  and 
divide  the  fascia  covering  its  under  surface.  Search 
for  the  intermuscular  septum  between  the  gluteus 
medius  and  the  pyriformis  muscles,  in  which  the 
arteiy  and  its  veins  will  be  found.  By  rotating  the 
hip-joint  outward,  the  wound  can  be  held  open  more 


OPEEATIONS  6>.V  THE  CIRCULATORY  SYSTEM.     93 

readily.     Ligate  the  artery  as  near  its  exit  from  the 
pelvis  as  possible,  as  it  soon  gives  off  its  branches. 

Sciatic  Aeteey. — Place  the  subject  on  the  belly. 

The  surface  guide  to  the  operation  is  a  line  drawn 
from  the  posterior  superior  spinous  process  of  the 
ilium  to  the  tuber  ischii. 

Make  an  incision  four  inches  long  parallel  to  the 
fibers  of  the  gluteus  maximus,  having  as  its  middle 
pomt  the  junction  of  the  lower  and  middle  thirds  of 
this  line.  Divide  the  integument  and  fascia,  and 
separate  the  fibers  of  the  gluteus  maximus  muscle. 
Divide  the  fascia  covering  the  under  surface  of  the 
gluteus  maximus  muscle.  The  artery  will  be  seen 
emerging  from  under  the  pyriformis  muscle.  In- 
ternally will  be  seen  the  pudic  vessels,  and  externally 
situated  will  be  seen  the  sciatic  nerve.  Pass  the 
needle  from  without  inward  to  avoid  the  vein. 

Ioteenal  Pudic  Aeteey.— 1.  The  artery  may  be 
exposed  by  the  last  operation.  It  is  found  just  in- 
ternal to  the  sciatic  artery,  emerging  from  under  the 
pyriformis  muscle,  accompanied  by  its  veins  and  the 
pudic  nerve. 

2.  In  the  Perinceum. — Place  the  subject  in  the 
lithotomy  position. 

The  surface  guide  is  a  line  drawn  from  below  the 
symphysis  pubis  to  the  inner  side  of  the  tuberosity 
of  the  ischium. 

Make  an  incision  in  this  line  three  inches  long, 
foUowino;  the  ramus  of  the  pubis  and  ischium,  and 
extending  nearly  to  the  tuberosity  of  the  ischium. 
Divide  the  integument  and  the  thick  layer  of  adipose 
tissue.  Separate  the  tissues  from  the  inner  side  of 
the   ramus.     Avoid   injuring   the   crus   penis.     The 


9J:  OPERATIVE  SURGERY  ON'  THE  CADAVER. 

artery  can  be  felt  about  an  incli  and  a  half  above  tlie 
tuber  iscliii.  The  ridge  formed  by  the  falciform 
process  of  the  great  sacro-sciatic  ligament  is  below 
the  artery.  Divide  the  obturator  fascia  which  covers 
the  artery,  and  pass  the  ligature,  avoiding  the  veins 
and  the  pudic  nerve. 

The  pudic  nerve  is  situated  internally  to  the  artery, 
and  its  branch,  the  perineal  nerve,  runs  below  the  ar- 
tery. 

ExTEE^AL  Iliac  Artery. — Place  the  subject  on 
the  back,  inclined  to  the  opposite  side,  and  slightly 
flex  the  hip-joint. 

The  surface  guide  is  the  lower  part  of  the  line  given 
as  the  guide  to  the  common  and  external  iliac  arteries. 

Begin  an  incision  a  little  internal  to  and  an  inch 
above  the  middle  point  of  Poupart's  ligament,  and 
continue  it  upward  and  outward  four  inches.  The 
incision  should  extend  nearly  parallel  to  Poupart's 
ligament,  but  slightly  more  concave  upward.  Divide 
the  skin  and  fascia.  Divide  on  a  director  the  apo- 
neurosis of  the  external  oblique,  the  internal  oblique 
muscle,  and  the  trans versalis  muscle.  Divide  the 
transversalis  fascia  to  the  extent  of  the  wound;  Sepa- 
rate the  peritonaeum  and  subserous  fat  upward  and 
inward  from  the  iliac  and  psoas  fasciae.  The  artery 
is  found  at  the  inner  border  of  the  psoas  muscle. 
Pass  the  needle  from  within  outward  to  avoid  the 
vein,  which  is  situated  internally  on  a  lower  level. 
Avoid  the  genital  branch  of  the  genito-crural  nerve, 
and  apply  the  ligature  about  two  inches  above  the 
level  of  Poupart's  ligament. 

Deep  Epigastric  Artery. — Place  the  subject  on 
the  back. 


OPERATION'S  OJSr  THE  CIRCULATORY  SYSTEM.     95 

Tlie  surface  guide  to  the  course  of  the  artery  is 
the  line  of  the  iliac  arteries. 

Make  an  incision  three  inches  long  one  inch  above 
and  parallel  to  Poupart's  ligament.  The  incision 
should  have  its  middle  point  over  the  course  of  the 
artery.  Divide  the  integument  and  fascia,  the  apo- 
neurosis of  the  external  oblique,  and  a  few  fibers  of 
the  internal  oblique  and  transversalis  muscles.  Di- 
vide on  a  director  the  transversalis  fascia  to  the 
extent  of  the  wound.  The  artery  will  be  seen  ex- 
tendino"  in  the  dii'ection  of  the  umbilicus.  Separate 
the  veins,  and  pass  the  needle. 

The  deep  circumflex  iliac  may  be  secured  through 
the  same  wound. 

Femoral  Arteey. — Place  the  subject  on  the  back. 
Semiflex  the  knee,  and  rotate  outward  the  hip-joint 
slightly  flexed. 

The  surface  guide  to  the  artery  is  the  upper  two 
thirds  of  a  line  drawn  from  a  point  midway  between 
the  anterior  superior  spinous  process  of  the  ilium  and 
the  symphysis  pubis  to  the  adductor  tubercle  on  the 
inner  condyle  of  the  femur. 

1.  Common  Femoral. — Begin  an  incision  one  half 
inch  above  Poupart's  ligament,  and  continue  it  down- 
ward three  inches  in  the  line  of  the  artery.  Divide 
the  integument  and  superficial  fascia,  avoiding  the 
lymphatic  glands.  Feel  Poupart's  ligament,  and  di- 
vide on  a  director  the  fascia  lata,  which  is  attached 
to  its  lower  border.  The  sheath  of  the  vessels  is  now 
exposed,  and  should  be  opened  one  half  inch  below 
Poupart's  ligament.  Pass  the  needle  from  within  out- 
ward, to  avoid  the  vein  which  is  inclosed  in  a  separate 
compartment  of  the  sheath  just  internal  to  the  artery. 


96         OPERATIVE  SURGERY  ON"  THE  CADAVER. 

2.  Superficial  Femoral  in  Scarpa'' s  Triangle. — 
Three  inches  below  Poupart's  ligament  begin  an  in- 
cision, and  extend  it  downward  three  inches  in  the 
line  of  the  artery.  Divide  the  integument  and  su- 
perficial fascia,  avoiding  the  internal  saphenous  vein. 
Divide  the  fascia  lata,  and  recognize  the  sartorius 
muscle  by  its  fibers  extending  downward  and  in- 
ward. Locate  the  artery  where  the  sartorius  and 
the  adductor  longus  muscles  meet.  Separate  and  re- 
tract outward  the  sartorius  muscle.  Pass  the  needle 
from  within  outward,  remembering  that  the  vein  is 
behind  as  well  as  internal,  and  hence  directing  the 
point  of  the  needle  toward  the  artery. 

3.  Superficial  Femoral  in  Hunter^  Canal. — Begin 
an  incision  in  the  middle  of  the  thigh,  and  extend  it 
downward  four  inches  in  the  line  of  the  artery.  Di- 
vide the  integument,  superficial  fascia,  and  the  fascia 
lata.  Pecognize  the  sartorius  muscle  by  its  fibers 
extending  downward  and  inward.  Separate  and  re- 
tract inward  the  sartorius  to  expose  the  dense  fascia 
formino;  the  roof  of  Hunter's  canal.  Search  for  a 
branch  of  the  artery  which  perforates  this  fascia  to 
locate  the  artery.  Divide  the  fascia  over  the  artery. 
Petract  outward  the  long  saphenous  nerve.  Pass  the 
needle  from  without  inward  to  avoid  the  vein  which 
is  in  contact  externally  and  posteriorly  with  the  ar- 
tery. 

The  femoral  artery  may  divide  in  the  upper  part 
of  its  course,  or  give  off  its  branches  irregularly.  It 
has  been  found  situated  posteriorly  to  its  usual 
course. 

Profunda  Femoeis  Artery. — Place  the  subject 
as  if  for  ligation  of  the  femoral  artery. 


OPERATIONS  ON  THE  CIRCULATORY  SYSTEM.     97 

Begin  an  incision  one  incli  below  Poupart's  liga- 
ment, and  extend  it  downward  three  incites  in  the 
line  of  the  femoral  artery.  Uncover  the  femoral  ar- 
tery and  find  on  its  outer  side,  or  posteriorly,  the 
origin  of  the  profunda  femoris.  Avoid  the  profunda 
vein  which  is  situated  in  front  of  the  artery.  Pass 
the  ligature  around  the  artery  about  three  quarters 
of  an  inch  from  its  origin. 

Popliteal  Artery. — Turn  the  subject  on  the  ab- 
domen. 

The  surface  guide  is  a  line  drawn  from  a  point 
one  inch  internal  to  the  upper  angle,  to  the  lower 
angle  of  the  popliteal  space. 

1.  Above  the  Knee- Joint. — Begin  an  incision  at  the 
upper  part  of  the  popliteal  space  and  extend  it  down- 
ward four  inches,  following  the  course  of  the  artery. 
Divide  the  integument  and  fascia.  Expose  the  fleshy 
fibers  of  the  semimembranosus  and  retract  the  muscle 
inward.  Tease  a  way  through  the  areolar  tissue,  until 
the  sciatic  nerve  is  encountered.  Internal  to  the  nerve 
and  nearer  the  femur,  the  vein  resting  upon  the  ar- 
tery will  be  found.  The  artery  is  situated  internally 
to  the  vein  resting  upon  the  femur.  Eetract  the 
nerve  and  vein  outward,  and  pass  the  needle  from 
without  inward. 

2.  Below  the  Knee-Joint. — Make  an  incision  four 
inches  long,  extending  in  the  course  of  the  artery  to 
the  lower  end  of  the  line  drawn  as  the  surface  guide. 
Divide  the  integument  and  fascia,  avoiding  the  ex- 
ternal saphenous  vein.  Tease  a  way  through  the 
areolar  tissue  between  the  heads  of  the  gastrocnemius 
muscle,  until  the  posterior  tibial  nerve  is  uncovered. 
External  and  deeper  in  the  tissues,  the  popliteal  vein, 


98  OPERATIVE  8URGEEY  ON  TEE  CADAVER. 

resting  on  tlie  artery,  is  to  be  found.  The  artery  is 
situated  externally  beneath  tbe  vein  resting  upon  the 
popliteus  muscle.  Ketract  the  nerve  and  vein  in- 
ward, and  pass  the  needle  from  within  outward. 

PosTEEioR  Tibial  Aeteey. — Turn  the  subject  on 
the  back.  Slightly  flex  the  knee  and  hip  joints,  and 
rotate  outward  to  make  the  limb  rest  upon  its  outer 
surface. 

The  surface  guide  is  a  line  drawn  from  the  lower 
angle  of  the  popliteal  space,  to  a  point  one  half  inch 
posterior  to  the  inner  malleolus. 

1.  In  Middle  of  Leg, — Make  an  incision  four 
inches  long,  parallel  to  and  one  inch  posterior  to  the 
inner  border  of  the  tibia.  Divide  the  integument 
and  fascia,  avoiding  the  internal  saphenous  vein. 
The  inner  border  of  the  gastrocnemius  can  be  seen 
resting  upon  the  soleus.  Cut  through  the  muscular 
and  tendinous  fibers  of  the  soleus  in  the  line  of  the 
primary  incision,  until  the  deep  fascia  is  reached. 
Separate  the  soleus  and  retract  it  outward,  the  mus- 
cle being  made  lax  by  extending  the  ankle-joint. 
Divide  on  a  director  the  deep  fascia  when  the  artery 
may  be  seen.  Retract  the  nerve  outward,  and  pass 
the  needle  from  without  inward,  avoiding  the  venae 
comites. 

2.  Posterior  to  Inner  Malleolus. — Flex  the  ankle- 
joint.  Make  an  incision  three  inches  long,  midway 
between  the  inner  border  of  the  tibia  and  the  tendo 
Achillis.  The  incision  should  extend  down  to  the 
level  of  the  lower  end  of  the  internal  malleolus.  Di- 
vide the  integument  and  superficial  fascia.  Divide 
on  a  director  the  deep  fascia.  Separate  the  tissues, 
to  uncover  the  artery  external  to  the  tendon  of  the 


OFERATIOHS  ON  THE  CIRCULATORY  SYSTEM.     99 

flexor  lono-us  dio-itorum  muscle.  Tlie  nerve  situated 
behind  and  externally  is  retracted  outward,  and  tlie 
needle  passed  from  without  inward,  avoiding  the  venae 
comites. 

Pero]s^eal  Aktery. — Slightly  flex  the  knee  and 
hip  joints,  and  rotate  inward  to  make  the  limb  lie 
with  its  outer  surface  uppermost.  The  course  of  the 
artery  is  just  internal  to  the  fibula. 

In  Middle  of  Leg. — Make  an  incision  four  inches 
long,  parallel  to  and  one  half  inch  posterior  to  the 
fibula.  Divide  the  integument  and  fascia.  Cut  the 
filular  attachment  of  the  soleus  to  the  extent  of  the 
wound.  Separate  the  soleus  from  the  fascia  covering 
the  flexor  longus  hallucis.  Extend  the  ankle-joint 
and  retract  the  soleus  inward.  The  artery  will  be 
found  just  internal  to  the  fibula  under  the  deep  fas- 
cia. It  may  be  found  in  the  substance  of  the  flexor 
longus  hallucis.     Pass  the  needle. 

AxTEEioR  Tibial  Aetery. — Place  the  subject  on 
the  back,  with  the  limb  extended. 

The  surface  guide  is  a  line  drawn  from  a  point 
on  the  anterior  surface  of  the  limb,  one  half  inch  in- 
ternal to  the  head  of  the  fibula,  to  a  point  midway 
between  the  malleoli  in  front  of  the  ankle-joint. 

1.  Middle  Third  of  Leg. — Make  an  incision  four 
inches  long  obliquely  downward  and  outward,  having 
its  middle  point  over  the  course  of  the  artery.  Di- 
vide the  integument  and  superficial  fascia.  Divide 
on  a  director  the  deep  fascia  which  will  require  hori- 
zontal cuts  to  allow  its  retraction.  Search  for  the 
outer  border  of  the  tibialis  anticus  muscle,  which 
may  be  made  more  evident  in  the  lower  part  of  the 
wound,  by  extending  the  ankle  and  turning  the  foot 


100       OPERATIVE  SURGERY  ON-  THE  CADAVER. 

outward.  Separate  tlie  tibialis  anticus  from  the  ex- 
tensor longus  digitorum,  do^vn  to  the  interosseous 
membrane.  The  artery  will  be  found  on  this  mem- 
brane mth  its  veins,  and  with  the  anterior  tibial 
nerve  in  front.  Retract  the  nerve  outward,  and  pass 
the  needle  from  without  inward. 

2.  Lower  Tliird  of  Leg. — Make  an  incision  three 
inches  long  in  the  line  of  the  artery.  Find  the  outer 
border  of  the  tibialis  anticus  tendon.  Separate  the 
tibialis  anticus  from  the  extensor  proprius  hallucis, 
whose  tendon  has  commenced  to  cross  over  to  the 
inner  side  of  the  artery.  The  artery  is  found  on  the 
interosseous  membrane,  with  the  nerve  situated  ex- 
ternally. Pass  the  needle  from  without  inward,  avoid- 
ing the  venae  comites. 

DoRSALis  Pedis  Artery.  —  Extend  the  ankle- 
joint. 

The  surface  guide  is  a  line  drawn  from  a  point 
in  front  of  the  ankle,  midway  between  the  malleoli 
to  the  first  metatarsal  interosseous  space. 

Make  an  incision  two  inches  long,  beginning  one 
inch  from  the  upper  end  of  this  line.  Divide  the 
integument  and  superficial  fascia.  Divide  on  a  di- 
rector the  dense  deep  fascia  along  the  outer  border 
of  the  tendon  of  the  extensor  proprius  hallucis,  made 
prominent  by  flexing  the  great  toe.  Separate  and 
retract  outward  the  extensor  brevis  digitorum,  the 
inner  tendon  of  which  crosses  over  the  artery.  The 
nerve  is  external.  Pass  the  needle  avoiding  the  venae 
comites. 

PHLEBOTOMY. 

Tie  a  ligature  tightly  around  the  arm  just  above 
the  elbow,  and  try  to  make  the  veins  prominent  by 


OPERATIONS  ON  THE  CIRCULATORY  SYSTEM.   101 

pressing  any  blood  whicli  is  fluid  in  the  forearm, 
up  toward  the  elbow. 

Select  the  median  cephalic  vein,  which  can  be  seen 
or  felt.  Grasp  the  forearm  just  below  the  elbow  with 
the  left  hand,  and  steady  the  vein  with  the  left 
thumb.  Hold  the  lancet  between  the  right  thumb 
and  index-finger,  with  its  blade  making  an  obtuse 
angle  with  the  hand.  Puncture  the  vein  obliquely, 
and  tilt  the  point  of  the  lancet  while  removing  it,  in 
order  to  enlarge  the  opening. 

If  the  external  jugular  is  chosen  for  operation, 
the  puncture  must  divide  the  fibers  of  the  platysma 
myoides.  Open  the  vein  as  it  crosses  the  sterno-cleido- 
mastoid  muscle,  making  the  length  of  the  opening  to 
run  upward  and  outward.  The  vein  is  made  promi- 
nent for  operation  by  placing  a  pad  above  the  middle 
of  the  clavicle  to  make  pressure  on  the  vein. 

The  internal  saphenous  vein  is  cut  obliquely 
above  the  inner  malleolus.' 

AETERIOTOMY. 

Locate  the  anterior  temporal  artery.  The  artery 
is  subcutaneous,  and  can  be  readily  followed  upward 
and  forward  from  the  temporal  artery. 

Divide  the  integument  over  the  artery.  Partially 
divide  the  artery  by  an  oblique  incision.  "When  the 
wound  is  to  be  closed  the  artery  must  be  completely 
divided  and  closed  by  compression,  torsion,  or  the 
ligature. 

TRAIS^SFUSIOT^. 

One  of  the  various  methods  may  be  practiced  on 
the  subject. 

Arterial  Transfusion. — (Prepare  a  fluid  for  trans- 


102        OPERATIVE  SURGERY  OJST  THE  CADAVER. 

fusion  by  adding  to  a  pint  of  distilled  water  one  and 
a  half  dracbm  of  common  salt  and  fifteen  grains  of 
carbonate  of  soda.  Keep  the  temperature  of  tlie 
fluid  at  104°  Falir.)  Expose  the  radial  artery,  and 
ligature  it  in  the  lowest  part  of  the  wound.  Occlude 
the  artery  by  means  of  forceps  applied  above  the  liga- 
ture, and  divide  the  vessel  between  the  forceps  and 
the  ligature.  Separate  the  artery  from  its  bed  to  the 
extent  of  an  inch.  Compress  the  artery  above  the 
wound.  Kemove  the  forceps,  and  introduce  into  the 
artery,  and  secure  with  a  ligature,  the  end  of  a  tro- 
car. Place  the  receptacle  holding  the  fluid  six  feet 
above  the  body,  and  attach  it  to  the  trocar  by  means 
of  rubber  tubing.  Allow  the  tubing  to  fill  with  fluid 
to  expel  the  air  before  attaching  it  to  the  trocar. 
Remove  the  pressure  on  the  artery  above  the  wound. 
Allow  several  ounces  of  the  fluid  slowly  to  enter  the 
arterial  system.  When  the  trocar  is  to  be  removed, 
the  artery  above  the  end  of  the  instrument  must  first 
be  ligated. 


Last  Lumbar  Artery. . . 


Epigastric  Artery 

Ilio-lnmbar  Artery 

Gluteal  Artery 

Lateral  Sacral  Artery. . 

Pubic  branch  of  Epi- ) 
gastric  Artery j 

Ischiatic  Artery 

Ascending  branch  of 
External  Circum- 
flex Artery 

Femoral  Artery 

Deep  Circ'mflex  Iliac  I 
Artery ( 

Internal    Circumflex  | 
Artery f 

External  Circumflex  I 

Artery f 

Profunda  Artery 

First  Perforating  A. . . . 

Descending  br'nch  of  ( 

Ext.  Circumflex  A.  ( 

Second  Perforating  A.. 

Third       Perforating  j 
Artery ) 


Superior  Extern'l  Ar-  > 
ticular  Artery. . .   .  j 

Inferior  External  Ar-  / 
ticular  Artery f 

Tibial  Recurrent  Ar-  / 
tery f 


Anterior  Tibial  Artery. 

Posterior  Tibial  Artery 
Peroneal  Artery 


Anterior 
Artery 

External  Plantar  Ar- 
tery  


Peroneal  ( 


Middle       Sacral 
Artery. 

["Visceral  branch- 
J  es  anastomos- 
1  ing  across  mid- 
t     die  line. 


Obturator. 


J  Artery  of  Great 
\     Sciatic  Nerve. 


Anastomotica 
Magna  Artery 


Superior  and  In- 
ferior Internal 
Articular  Ar- 
teries. 


Communicating  A. 
Malleolar  Arteries. 

j  Internal  Plantar 
I     Artery. 

Dorsalis      Pedis 

Artery. 


Diagram  of  Collateral  Circulation  after  Ligatures  of  Arteries  of  Abdomen  and 

Lower  Extremity.  (Smith  and  Walsham.) 


Circle  of  Willis 

Basilar  Artery 

Occipital  Artery 

External  Carotid 

Princeps  Cervicis  Artery 

Vertebral  Artery 

Common  Carotid 

Anastomosis  between  1 
Superior  and  Inferior  V 
Thyroid  Arteries ) 

Deep  Cervical  Artery 


Posterior  Scapular  Artery 
Suprascapular  Artery.  .. 
Subclavian  Artery 

Superior  Intercostal  Ar-  > 
tery | 

Axillary  Artery 

Short  Thoracic  Artery. . . 

Posterior  Circumflex  A. . . 

Anastomosis  between 
the  Posterior  Scapular 
and  Dorsalis  Scapulse 

Subscapular  Artery  . . . 

Long  Thoracic  Artery. . 

Anastomosis     between 
Internal      Mammary, 
Lon^    Thoracic,  and  j- 
Aortic      Intercostals 
Arteries J 

Brachial  Artery 

Inferior  Profunda 

Anastomosis  between  1 
Superior  Profunda  j 
and  Interosseous  Ee-  } 
current  Artery J 

Ditto  between  Superior 
Profunda  and  Kadial  > 
Recurrent  Arteries. . . 

Posterior    Interosseous 

Artery )' 

Anterior  Interosseous  A 


Posterior  Branch  and 
Anterior  Branch  of 
Anterior  Interosseous 

Anterior  Carpal  Artery. 

Posterior  Carpal 

Carpal  Recurrent    

Deep  Palmar  Arch 

Superficial  Palmar  Arch 


A,  Aorta. 

B.  Innominate  Artery. 

c,  D,  and  E,  Anastomosis  between  the  Inferior 
Profunda,  Anastomotica  Magna,  and  An- 
terior and  Posterior  Ulnar  Recurrent. 

R,  Radial  Artery. 

u,  Ulnar  Artery. 

M,  Anastomosis  between  the  Internal  Mam- 
mary and  Deep  Epigastric  Arteries. 


Diagram  of  the  Collateral  Circulation  of  the  Arm. 

(Smith  and  Walsham.) 


CHAPTER  X. 

OPERATIONS  ON  THE  OSSEOUS  SYSTEM. 
MANTPULATIO]^    OF    THE    SAW. 

1.  Hoiv  to  Jiold, — Hold  the  saw  in  the  full  grasp  of 
the  hand,  with  the  index-finger  placed  along  the  side. 

2.  How  to  use, — Before  a  saw  can  be  freely  moved 
to  and  fro,  a  groove  must  be  made  in  the  bone  to  re- 
tain it  in  position. 

In  the  case  of  a  trephine,  the  central  pin  controls 
the  movement  of  the  crown  until  a  groove  is  cut. 

A  chain-saw  is  conducted  into  position  by  a  needle 
or  probe,  to  which  it  is  attached  by  a  ligature.  The 
chain  should  not  be  twisted,  and  its  cutting-edge 
must  be  presented  to  the  bone.  The  chain  should 
be  kept  taut,  and  as  nearly  straight  as  the  depth  of 
the  wound  in  the  soft  parts  vdll  allow.  To  keep  the 
chain  taut,  the  two  arms  of  the  operator  must  move 
in  unison.  Hold  the  handles  in  the  palm,  allowing 
the  chain  to  pass  between  the  middle  and  ring  fin- 
gers. 

The  ordinary  saw  must  be  steadied,  and  a  groove 
in  the  bone  be  established,  by  drawing  the  saw  to- 
ward the  operator.  The  left  thumb-nail,  applied  just 
above  the  level  of  the  teeth,  will  steady  the  instru- 
ment. 


104:       OPERATIVE  8UE0ERY  OJST  THE  CADAVER. 

If  the  saw  is  moved  rapidly,  the  heat,  which 
would  be  excessive,  must  be  prevented  by  irrigation. 
When  the  bone  is  nearly  severed,  the  undivided  por- 
tion bends  and  the  track  of  the  saw  is  narrowed, 
hence*  the  saw  should  then  be  presented  to  the  bone 
at  a  different  ans-le. 

o 

OSTEOTOMY. 

Various  instruments  are  used  to  cut  bones,  as 
saws,  chisels,  osteotomes,  scoops,  etc.  The  use  of  the 
osteotome,  in  making  a  section  of  the  bone  in  this 
operation,  must  be  considered  a  matter  of  choice. 

Example:  Middle  of  the  Tibia, — Place  the  sub- 
ject on  the  back.  Shave  the  part.  Adjust  a  sand- 
pillow  under  the  limb  at  the  site  of  the  operation. 

Select  the  subcutaneous  portion  of  the  tibia. 
Draw  the  skin  upward  so  that  the  wound  will  be 
valvular.  Make  an  incision  in  the  long  axis  of  the 
limb  through  all  the  tissues.  There  are  no  impor- 
tant structures  to  be  avoided.  The  incision  should  be 
long  enough  to  admit  the  osteotome,  which  should 
be  inserted  with  its  cutting  edge  in  the  axis  of  the 
wound  until  it  touches  the  bone.  Hold  the  osteotome 
at  a  right  angle  to  the  bone,  and  turn  it  so  that  its 
cutting  edge  is  presented  to  the  bone  crosswise. 
Strike  the  head  of  the  osteotome  with  a  mallet,  and 
then  move  the  osteotome  in  the  axis  of  its  cutting 
edge  to  prevent  its  becoming  wedged.  When  the 
section  is  deep  and  the  osteotome  is  moved  with 
difficulty,  a  narrower  and  thinner  osteotome  must  be 
substituted.  The  smaller  osteotome  can  be  directed 
backward  and  outward  and  backward  and  inward  in 
the  wound  made  by  the  larger  osteotome.     When  the 


OPEEATIONS  0.¥  THE  OSSEOUS  SYSTEM.         105 

section  is  nearly  completed,  the  bone  is  broken  witli 
slight  force. 

Place  tlie  limb  in  the  desired  position,  and  close 
the  wound,  providing  for  drainage. 

WIKES^a    OF   BONES. 

Example:  Fractured  Patella. — Prepare  the  sub- 
ject by  fracturing  or  subcutaneously  dividing  the  pa- 
tella and  separating  its  fragments  by  flexing  the  knee- 
joint.     Place  the  subject  on  the  back. 

Make  a  horizontal  incision  from  the  posterior  part 
of  the  lateral  surface  of  one  condyle  of  the  femur 
across  the  front  of  the  joint,  to  the  corresponding  point 
on  the  other  condyle.  The  incision  should  cross  the 
joint  on  the  level  of  the  upper  margin  of  the  lower 
fragment  of  the  patella.  Divide  all  the  tissues,  thus 
freely  opening  the  joint.  Turn  the  fractured  surface 
of  each  bone  upward,  and  make  them  smooth  by 
means  of  a  bone-scoop. 

Enter  a  bone-drill  in  the  middle  line  of  the  ante- 
rior surface  of  the  patella,  a  third  of  an  inch  from 
the  anterior  margin  of  the  fractured  surface.  Bore 
the  bone  obliquely,  piercing  through  the  fractured 
surface  near  the  layer  of  cartilage  which  covers  its 
posterior  surface.  After  each  fragment  is  perforated, 
a  stout  silver  wire  is  pushed  through  the  track  of 
the  drill,  following  the  point  of  the  drill  as  it  is 
withdrawn.  A  single  wire  is  sufficient.  Approxi- 
mate the  fragments  by  dravring  the  ends  of  the  wire 
forward.  Use  care  to  be  assured  that  no  tissue  nor 
foreign  substance  is  included  between  the  fractured 
surfaces.  Twist  the  ends  of  the  wire  together  until 
all  the  slack  is  taken  up. 


106       OPERATIVE  SURGERY  ON'  THE  CADAVER. 

Cut  tlie  twisted  ends  of  the  wire  one  lialf  incli 
from  the  surface  of  the  patella,  and  bend  them  down 
against  the  bone,  a  cut  through  the  periosteum  being 
made  over  the  bone  to  receive  them.  Cut  along  the 
^Txe  as  it  lies  over  the  patella,  so  that  the  wire  can 
be  pressed  flat  against  the  bone. 

Provide  for  drainage  from  the  joint  at  the  two 
angles  of  the  wound.  Stitch  accurately  together  the 
capsule  of  the  joint  and  the  tissue  on  the  fragments 
of  the  patella,  by  means  of  a  continuous  suture  of 
cutgut.  The  joint  is  thus  closed  and  separated  from 
the  wound  of  the  superficial  tissues.  Close  the  su- 
perficial wound,  after  providing  for  drainage.  No 
vessels  of  importance  are  divided  in  this  operation. 

EXCISION    OF    THE    SUPEEIOR    MAXILLA. 

Place  the  subject  on  the  back,  with  the  head 
slightly  elevated  on  a  block.  Operate  from  the  right- 
hand  side,  facing  the  subject. 

Extract  the  middle  incisor  tooth  of  the  bone  to 
be  removed.  Make  an  incision  through  the  median 
line  of  the  upper  lip  to  the  septum  nasi,  and  extend 
it  into  the  nostril  of  the  side  from  which  the  bone 
is  to  be  excised.  Curve  the  incision  around  the  cor- 
responding ala,  and  extend  it  upward  in  the  furrow 
between  this  side  of  the  nose  and  the  cheek,  to  a 
point  one  half  of  an  inch  below  the  inner  canthus  of 
the  eye.  Join  to  the  upper  end  of  this  incision  an 
incision  extending  just  below  the  inferior  margin  of 
the  orbit  to  the  malar  bone  (Fergusson).  These  in- 
cisions should  divide  all  the  tissues  to  the  bone. 
Ligate  the  divided  angular  artery.  Dissect  the  tis- 
sues from  the  bone,  leaving  undivided  the  reflexion 


OPERATIOl^S  ON  THE  OSSEOUS  SYSTEM.         107 

of  mucous  membrane  from  the  external  surface  of 
tlie  alveolar  process  to  the  flap. 

Begin  at  a  point  one  half  of  an  inch  from  the 
middle  of  the  posterior  margin  of  the  hard  palate  to 
make  an  incision  through  the  periosteum  extending 
along  the  median  line  to  the  space  caused  by  the  ex- 
traction of  the  middle  incisor  tooth.  Extend  this 
incision  up  over  the  alveolar  process  until  it  meets 
the  incision  dividing  the  upper  lip. 

Separate  the  ala  and  side  of  the  nose  attached  to 
the  nasal  process  of  the  bone,  and  retract  these  parts 
in  toward  the  septum.  Incise  the  tissues  on  the  floor 
of  the  nostril  along  the  side  of  the  septum,  and,  with 
a  narrow  saw,  divide  the  alveolar  process  and  hard 
palate  in  this  line. 

Strip  up  with  an  elevator  the  periosteum  from 
the  floor  of  the  orbit,  and  expose  the  spheno-maxil- 
lary  fissure.  Protect  the  eye  by  holding  the  tissues 
of  the  orbit  upward  with  the  elevator,  while  the  nasal 
process  is  sawn  through  to  the  internal  inferior  angle 
of  the  orbit.  Divide  with  a  scalpel  the  floor  of  the 
orbit  from  the  internal  inferior  angle  to  the  spheno- 
maxillary fissure,  cutting  close  to  the  margin.  Saw 
from  a  point  opposite  the  spheno-maxillary  fissure  the 
malar  bone  downward  and  outward,  just  internal  to 
the  most  prominent  part  of  the  bone. 

Cut  with  a  scalpel  the  mucous  membrane  reflected 
from  the  external  surface  of  the  alveolar  process  to 
the  flap  formed  by  the  cheek,  to  a  point  posterior 
to  the  last  molar  tooth.  Make  a  transverse  incision 
through  the  periosteum,  joining  this  incision  behind 
the  last  molar  tooth  to  the  median  incision  through 
the  hard  palate. 


108        OPERATIVE  8UEGERY  ON  THE  CADAVER. 

Grasp  tlie  bone  by  means  of  lion  forceps  and 
force  it  down,  to  break  tlie  palatine  and  pterygoid  at- 
tachments. Twist  the  bone  and  tear  it  from  its  other 
attachments. 

Cut  the  superior  maxillary  nerve  short,  and  ligate 
the  internal  maxillary  artery  in  the  location  of  the 
spheno-maxillary  fossa. 

The  cutting  forceps  may  supplement  the  use  of 
the  saw,  and  a  saw  may  be  used  to  divide  the  floor 
of  the  orbit  instead  of  the  scalpel. 

An  excision  leaving  the  inferior  margin  of  the  or- 
bital fossa  may  be  made  The  operation  is  performed 
in  every  respect  like  the  last,  except  in  separating  the 
bone  superiorly.  Drill  or  trephine  the  antrum  just 
below  the  middle  of  the  inferior  margin  of  the  or- 
bital fossa,  so  as  to  admit  a  narrow  saw.  Proceed- 
ing internally,  saw  horizontally  the  anterior  wall  of 
the  antrum  and  through  the  nasal  process  into  the 
nasal  fossa.  Proceeding  externally,  saw  horizontally 
throuo^h  the  anterior  wall  of  the  antrum  and  ob- 
liquely  downward  and  outward  when  the  malar  bone 
is  reached. 

An  excision  may  be  performed,  leaving  the  inter- 
maxillary bone.  In*  this  case  the  canine  tooth  is 
drawn,  and  the  alveolar  process  sawn  through  the  in- 
cisor fissure.  The  other  steps  of  the  operation  are 
the  same  as  those  just  described. 

These  excisions  may  be  practiced  sub-periosteally, 
by  incising  the  gum  down  to  the  bone  along  the  alveo- 
lar process  internally  and  externally,  just  above  the 
teeth.  Join  the  incisions  behind  the  last  molar,  and 
through  the  space  left  after  either  the  incisor  or  canine 
tooth  has  been  extracted.     Separate  the  tissues  from 


OPERATIONS  ON'  THE  OSSEOUS  SYSTEM,         109 

tlie  external  surface  of  tlie  alveolar  process,  leaving 
them  attached  to  the  flap.  Separate  the  tissues  from 
the  internal  surface  of  the  alveolar  process,  and  from 
the  hard  palate  as  far  as  the  median  line.  In  the 
operation  where  the  intermaxillary  bone  is  to  remain, 
an  incision  is  carried  from  the  socket  of  the  extracted 
canine  tooth  to  the  median  line  following  the  incisor 
fissure.  In  sawing  the  alveolar  process  and  hard  pal- 
ate, be  careful  that  the  gum  and  periosteal  flap  are 
protected.  In  stitching  together  the  wound,  the 
flaps  removed  from  each  side  of  the  alveolar  process 
are  brought  in  apposition. 

The  part  of  the  facial  flap  made  by  dividing  the 
upper  lip  will  need  stitches  of  relaxation. 

If  both  bones  are  removed  simultaneously,  the 
same  incisions  (Fergusson)  are  to  be  made  on  the 
other  side.  Separate  the  septum  from  the  nasal  crest. 
The  two  maxillse  are  not  to  be  sawn  between,  but  re- 
moved together. 

EXCISIOIS-    OF    TIIE    INFEEIOR    MAXILLA. 

Place  the  subject  on  the  back,  with  the  head 
slightly  raised  upon  a  block.  Stand  on  the  right- 
hand  side,  facing  the  subject. 

First,  one  half  of  the  bone  is  removed  as  follows : 
Extract  the  middle  incisor  tooth  of  the  half  to  be  re- 
moved. Make  an  incision  through  the  middle  of  the 
lower  lip  to  a  point  just  below  the  symphysis  menti, 
cutting  down  to  the  bone.  Join  to  the  lower  end  of 
this  incision  another  extending  along  the  lower  bor- 
der of  the  body,  around  the  angle,  and  upward,  im- 
mediately posterior  to  the  ramus  of  the  bone,  until 
the  level  of  the  lobe  of  the  ear  is  reached.     The  fa- 


110        OPERATIVE  SURGERY  ON   TEE  CADAVER. 

cial  artery  is  divided  between  ligatures,  as  it  crosses 
the  bone  in  a  line  witli  tlie  anterior  edge  of  the  mas- 
seter  muscle.  Separate  the  flap  thus  marked  out  from 
the  bone,  by  means  of  the  scalpel  and  elevator,  and 
reflect  it  upward. 

Divide  with  a  narrow  saw  the  bone  downward 
and  outward  from  the  space  formed  by  the  extraction 
of  the  middle  incisor  tooth  to  a  point  external  to  the 
genial  tubercles. 

Catch  the  divided  end  of  the  bone  with  the  lion 
forceps  and  draw  it  upward  and  outward,  while 
the  tissues  from  the  inner  surface  and  inferior  bor- 
der of  the  body  are  separated  by  means  of  the  scal- 
pel and  elevator.  Guard  against  the  division  of  the 
lingual  nerve,  by  keeping  the  edge  of  the  knife 
directed  toward  the  bone  while  separating  the  tis- 
sues below  the  molar  teeth.  Turn  the  bone  out- 
ward, and  cut  the  muscular  insertions  from  the  in- 
ternal surface,  and  the  anterior  edge  of  the  coronoid 
process,  also  the  insertion  of  the  internal  pterygoid. 
Cut  the  inferior  dental  vessels  and  nerve  as  they  en- 
ter their  canal.  Grasp  the  bone  and  depress  it.  Cut 
the  muscular  attachment  and  the  capsular  ligament 
on  the  anterior  surface  of  the  neck  of  the  bone.  Dis- 
locate the  condyle  and  twist  it  loose,  cutting  an}^  at- 
tachments not  torn  or  peeled  oft'.  Keep  the  edge  of 
the  knife  against  the  bone,  as  the  internal  maxillary 
artery  is  just  behind  and  internal  to  the  neck.  Tie 
the  inferior  dental  artery. 

If  it  is  necessary  to  prolong  the  external  incision 
upward  to  the  condyle,  to  effect  the  disarticulation, 
Stenson's  duct,  the  transverse  facial  artery,  and 
branches  of  the  facial  nerve  will  be  divided. 


OPERATION'S  ON'  TEE  OSSEOUS  SYSTEM.         l\\ 

Before  beginning  the  removal  of  the  other  half  of 
the  bone,  pass  a  ligature  through  the  anterior  part  of 
the  tongue  and  draw  it  forward. 

Separate  the  attachments  of  the  muscles  arising 
from  the  genial  tubercles,  and  proceed  as  in  the  re- 
moval of  the  first  half.  Stitch  the  mucous  membrane 
together,  and  provide  for  drainage  externally.  Use 
stitches  of  relaxation  to  secure  the  coaptation  of  the 
incision  through  the  lip. 

Kesections  of  different  portions  of  the  bone  are 
best  performed  through  external  incisions  following 
the  course  of  that  for  excision.  It  is  never  necessary 
in  these  partial  excisions  to  divide  the  lip. 

Before  the  muscular  attachments  to  the  genial 
tubercles  are  severed,  always  secure  the  tongue  by 
means  of  a  ligature  passed  through  its  anterior  part. 
After  the  operation,  suture  these  muscles  to  the  tis- 
sues removed  anteriorly  from  the  symphysis  menti. 

EESECTION    OF    EIB. 

Place  the  subject  in  such  a  position  that  the  por- 
tion of  bone  to  be  removed  is  uppermost. 

Make  an  incision  along  the  middle  of  the  body  of 
the  rib,  extending  a  little  beyond  each  end  of  the 
portion  to  be  removed.  Join  to  each  end  of  this  in- 
cision a  vertical  incision,  extending  from  the  upper 
to  the  lower  border  of  the  rib.  These  incisions  must 
divide  the  periosteum.  Eaise  all  the  tissues  from  the 
bone  by  means  of  a  periosteum  elevator  until  the  ex- 
ternal surface  and  upper  and  lower  borders  are  bare. 
Proceed  with  care  to  separate  the  periosteum,  covered 
by  the  pleura,  from  the  internal  surface.  The  inter- 
costal vessels  run  in  the  groove  near  the  lower  border, 


112        OPERATIVE  SURGERY  OJST  TEE   CADAVER. 

from  wliicli  tliey  must  be  dislodged  by  means  of  the 
elevator  and  scalpel. 

When  the  portion  of  bone  is  separated  from  all 
of  its  attachments,  carry  a  chain-saw  under  it  and 
saw  through  one  end.  Protect  the  pleura  with  a 
spatula  while  sawing.  Seize  the  divided  end  of  the 
poii:ion  of  bone  to  be  removed  with  lion  forceps  to 
steady  it  while  the  resection  is  completed.  Provide 
for  drainage,  and  stitch  the  flaps  together. 

eesectio:n'  of  the  aeticulating  ends  of  eones.* 

Shoulder- Joint. — Place  the  subject  on  the  back, 
with  the  shoulders  raised  on  a  block.  Draw  the 
shoulder  near  the  edge  of  the  table,  and  stand  on  the 
side  of  the  operation  facing  the  subject.  Kotate  the 
joint  inward,  so  that  the  external  condyle  of  the  hu- 
meiTis  is  directed  forward. 

Begin  an  incision  just  below  the  acromio-clavicu- 
lar  articulation,  and  extend  it  four  or  %^%  inches 
downward  in  the  middle  of  the  anterior  surface  of 
the  limb.  Divide  the  integument  and  fascia,  and  the 
inner  fibers  of  the  deltoid  muscle.  Retract  the  sides 
of  the  Avound,  and  feel  the  bicipital  groove  of  the 
humerus.  Open  the  sheath  of  the  tendon  of  the  long 
head  of  the  biceps,  and  the  capsule  of  the  joint  up  to 
the  acromion  process,  by  cutting  along  the  external 
edge  of  the  tendon  from  below  upward.  Kaise  the 
tendon  from  the  bicij^ital  groove  and  retract  it  out- 
ward. 

Incise  the  periosteum  along  the  inner  margin  of 
the  bicipital  groove,  and  separate  it  from  the  bone 

*  These  operations  should  be  modified  in  young  subjects  to  preserve 
the  epiphyseal  cartilages. 


OPFRATIOJ^fS  ON'  THE  OSSEOUS  SYSTEM.         113 

as  far  internally  as  possible,  by  means  of  an  elevator 
rotating  the  joint  outward.  The  elevator  should  not 
be  pointed,  nor  have  a  sharp  edge.  The  attachment 
of  the  subscapularis  muscle  to  the  lesser  tuberosity  is 
separated  by  means  of  a  scalpel.  The  edge  of  the 
scalpel  must  always  be  directed  toward  the  bone. 

Eotate  the  joint  inward  and  retract  inward  the 
tendon  of  the  long  head  of  the  biceps  muscle.  Incise 
the  periosteum  along  the  external  margin  of  the  bi- 
cipital groove.  Separate  the  periosteum  as  far  out- 
ward as  possible,  rotating  the  joint  inward.  The  at- 
tachments of  the  supra-spinatus,  infra-spinatus,  and 
teres  minor  muscles  to  the  greater  tuberosity  of  the 
humerus  must  be  separated  by  means  of  the  scalpel. 
The  anterior  and  posterior  circumflex  vessels,  and  the 
posterior  circumflex  nerve,  are  not  in  danger  if  the 
edge  of  the  elevator  and  scalpel  are  directed  toward 
the  bone  during  their  use. 

Care  must  be  exercised  that  the  periosteum  is  not 
lacerated  during  its  separation  from  the  surgical  neck 
of  the  bone. 

Pass  a  chain-saw  over  the  head,  behind  the  surgical 
neck  of  the  bone.  Protect  the  sides  of  the  wound  by 
means  of  spatulas  to  prevent  the  friction  of  the  chain- 
saw  against  them.  Saw  the  bone  through  and  re- 
move it  from  its  cavity.  The  glenoid  cavity  is  to  be 
examined. 

If  the  separation  of  the  tissues  posteriorly  is  imprac- 
ticable, the  upper  extremity  of  the  bone  may  be  sawn 
off  and  removed.  The  divided  upper  end  may  now 
be  directed  to  the  w^ound  and  the  tissues  separated, 
when  the  saw  can  be  carried  over  the  end  to  the  surgi- 
cal neck.     Provide  for  drainage,  and  close  the  wound. 


114        OPERATIVE  SURGERY  ON  THE  CADAVER, 

Elhoiv-Joint  (Park). — Extend  the  joint  and  raise 
the  limb  so  that  the  posterior  surface  is  accessible* 
Stand  on  the  outside  of  the  limb. 

Make  an  incision  ^yq  inches  long  in  the  middle  of 
the  posterior  surface  of  the  limb,  having  its  middle 
point  over  the  olecranon  process  near  to  its  internal 
border.     Divide  all  the  tissues  to  the  bone. 

Internally  to  the  wound,  separate  the  tissues  from 
the  posterior  surface  of  the  humerus  and  the  olec- 
ranon process  by  means  of  a  scalpel  and  periosteum 
elevator.  Carefully  separate  the  tissues  in  the  groove 
between  the  olecranon  and.  the  internal  condyle.  The 
ulnar  nerve  is  not  to  be  exposed.  Separate  the  mus- 
cular attachments  from  the  internal  condyle,  flexing 
the  joint  when  convenient.  The  ulnar  nerve  is  pro- 
tected by  the  left  thumb-nail,  and  the  edge  of  the 
scalpel  is  to  be  directed  toward  the  bone.  Eetract 
the  tissues  and  divide  the  internal  lateral  ligament  of 
the  joint. 

Externally  to  the  wound  separate  the  tissues  from 
the  bones  by  means  of  the  scalpel  and  periosteum  ele- 
vator. Detach  the  muscles  from  the  external  con- 
dyle, preserving  as  before  their  attachment  to  the 
periosteum.  Eetract  the  tissues  and  divide  the  ex- 
ternal lateral  lig-ament  alons;  the  lower  border  of  the 
external  condyle  of  the  humerus. 

Separate  from  the  ulna  the  olecranon  process,  by 
means  of  bone-cutting  forceps  or  the  saw.  In  using 
bone-cutting  forceps,  the  flat  surface  should  be  placed 
toward  the  shaft  of  the  bone  to  prevent  splintering. 

Flex  the  joint  and  force  the  lower  end  of  the  hu- 
merus out  of  the  wound.  Separate  the  tissues  at- 
tached to  the  anterior  surface,  no  special  care  being 


OPERATION'S  OJSr  TEE  OSSEOUS  SYSTEM.         115 

taken  to  preserve  the  periosteum.  Avoid  tlie  bra- 
chial artery  and  tlie  median  nerve.  Saw  the  bone 
through  at  a  right  angle  to  the  shaft  above  the  con- 
dyles. Allow  the  humerus  to  return  into  the  wound 
cavity. 

Push  the  ends  of  the  radius  and  ulna  into  the 
opening  of  the  wound.  Detach  the  tissues  from  the 
ulna  and  radius,  down  to  the  level  of  the  lower  bor- 
der of  the  coronoid  proc3SS.  Saw  the  bones  through 
at  this  level.  The  tubercle  of  the  radius  is  not  to  be 
sacrificed,  and  special  care  must  be  given  to  preserve 
the  attachment  of  the  brachialis  anticus  to  the  peri- 
osteum. Draw  the  bones  into  the  wound  cavity,  and 
approximate  them  to  the  humerus  at  a  right  angle. 

Wrist, — (Excision  of  the  carpus  with  resection  of 
the  carpal  ends  of  the  radius  and  ulna,  and  of  those 
of  the  metacarpus.)  Place  the  hand  prone  and  ad- 
ducted  upon  the  table. 

Begin  an  incision  one  half  of  an  inch  above  the 
wrist- joint,  a  little  nearer  to  the  inner  than  to  the 
outer  border  of  the  dorsal  surface  of  the  radius,  and 
continue  it  downward  to  the  middle  of  the  dorsal  sur- 
face of  the  second  metacarpal  bone.  Divide  the  in- 
tegument and  fascia,  the  tendon  of  the  extensor  carpi 
radialis  brevior  muscle,  the  periosteum,  and  posterior 
ligaments. 

On  the  radial  side  of  the  incision,  detach  by  means 
of  a  scalpel  the  extensor  carpi  radialis  longior  from 
the  second  metacarpal  bone.  Extend  the  wrist,  and 
use  an  elevator  to  separate  the  remaining  attachments, 
guarding  against  wounding  the  radial  artery.  Ke- 
tract  the  tissues  and  separate  by  means  of  bone-nip- 
pers the  trapezium  from  the  remainder  of  the  carpus. 


116        OPERATIVE  SURGERY  ON  TEE  CADAVER, 

On  the  ulnar  side  of  tlie  incision,  tlie  wrist  being 
extended,  separate  by  means  of  an  elevator  the  tis- 
sues from  the  bones. 

Beofin  a  second  incision  two  inches  above  the 
wrist-joint,  between  the  flexor  carpi  ulnaris  and  the 
ulna,  and  continue  it  downward  to  the  level  of  the 
middle  of  the  fifth  metacarpal  bone.  This  incision 
should  run  just  anterior  to  the  ulna  and  the  lifth 
metacarpal  bone.  Separate  by  means  of  a  scalpel  the 
attachment  of  the  extensor  carpi  ulnaris  from  the  fifth 
metacarpal  bone.  Extend  the  wrist,  and  complete 
the  separation  of  the  tissues  from  the  dorsal  surface 
of  the  bones. 

Flex  the  wrist  and  separate  the  tissues  from  the 
palmar  surface,  cutting  the  pisiform  bone  and  the 
unciform  process  from  the  rest  of  the  carpus,  by 
means  of  the  bone-cutting  forceps.  Do  not  use  the 
scalpel  in  separating  the  tissues  below  the  heads  of 
the  metacarpal  bones,  on  account  of  the  proximity  of 
the  deep  palmar  arch. 

Ketract  the  tissues  above  and  below,  and  by  means 
of  cutting  forceps  separate  the  carpus  from  the  radius 
and  triangular  cartilage  above  and  from  the  metacar- 
pus below.  The  carpus  can  now  be  removed  through 
the  wound  on  the  ulnar  side.  Dissect  out  the  trape- 
zium, avoiding  the  radial  vessels,  and  the  pisiform 
bone  and  the  unciform  process,  avoiding  the  ulnar 
vessels  and  nerve. 

Push  the  metacarpal  bones  into  the  wound,  and 
saw  off  their  articular  surfaces.  Separate  the  tissues 
from  the  head  of  the  ulna,  avoiding  the  ulnar  ves- 
sels and  nerve,  and  saw  off  its  articulating  surfaces. 
Separate  the  tissues  from  the  carpal  end  of  the  ra- 


OPERATIONS  ON  THE  OSSEOUS  SYSTEM.         117 

dius,  avoidino;  the  radial  vessels.  Protrude  the  bone 
and  saw  off  its  articulating  surface  on  a  level  with 
the  sawn  end  of  the  ulna. 

Search  for  the  detached  tendons  of  the  extensors 
of  the  carpus,  shave  off  slightly  their  surface  toward 
the  dorsum  of  the  hand,  and  attach  them  with  catgut 
to  the  periosteum  over  the  sawn  ends  of  their  respect- 
ive metacarpal  bones.  Appose  to  the  sawn  ends  of 
the  radius  and  ulna  those  of  the  metacarpus. 

Metacarpo-phalangeal. — Place  the  hand,  with  the 
fingers  extended,  prone  upon  the  table. 

Make  aiL  incision  two  inches  long  over  the  dorsal 
surface  of  the  bones,  with  its  middle  point  over  the 
joint.  In  the  case  of  the  thumb,  the  incision  should 
be  a  little  to  the  radial  side,  and  in  case  of  the  little 
finger,  a  little  to  the  ulnar  side  of  the  middle  of  the 
dorsal  surface.  Divide  the  integument  and  fascia. 
Push  aside  the  dorsal  tendons  and  incise  the  perios- 
teum. Separate  by  means  of  an  elevator  the  perios- 
teum from  the  ends  of  the  bones  for  haK  an  inch,  and 
cut  the  ligaments  of  the  joint.  Forcibly  flex  the 
joint  to  protrude  the  head  of  the  metacarpal  bone. 
Saw  oft'  the  articular  surface.  Protrude  the  base  of 
the  phalanx  through  the  wound,  and  saw  off  its  ar- 
ticular surface. 

Phalangeal. — Extend  the  finger. 

Make  longitudinal  incisions,  about  an  inch  long, 
on  the  sides  of  the  finger  nearer  the  dorsal  than  the 
palmar  surface.  The  middle  of  the  incisions  should 
correspond  to  the  joint.  Divide  the  tissues  to  the 
bones.  Elevate  the  tissues  from  the  head  of  the 
proximal  phalanx,  and  divide  the  lateral  ligaments  of 
the  joint.     Bend  the  finger  laterally  to  protrude  the 


118        OPERATIVE  SURGERY  ON  THE   CADAVER. 

head  of  tlie  proximal  phalanx.  Saw  off  the  head  of 
the  proximal  phalanx.  Push  the  base  of  the  more 
distal  phalanx  into  the  opening,  and  separate  the  tis- 
sues from  its  base  by  means  of  a  scalpel.  Protrude 
the  end  of  the  bone  and  saw  off  the  articular  sur- 
face. 

Hij^  (Langenbeck). — Place  the  subject  on  the 
back,  inclined  to  the  opposite  side.  Flex  the  hip- 
joint  until  the  thigh  is  at  an  angle  of  45°  with  the 
axis  of  the  body. 

Make  an  incision  about  six  inches  long  in  the  axis 
of  the  limb,  with  its  middle  point  over  the  middle 
of  the  superior  border  of  the  great  trochanter.  Di- 
vide the  integument  and  fasciae.  Incise  the  perios- 
teum on  the  trochanter,  and  separate,  by  means  of  the 
scalpel  and  elevator,  the  tissues  from  the  superior 
border  and  outer  surface.  Separate  the  fibers  of  the 
gluteus  maximus  muscle,  and  divide  on  a  director  the 
fascia  covering  its  deep  surface. 

Push  aside  the  tissues  to  expose  the  neck  of  the 
femur  and  retract  the  sides  of  the  wound.  Incise  the 
capsule  and  periosteum,  cutting  on  the  long  axis  of 
the  neck  of  the  femur.  Separate  the  tissues  from  the 
neck.  The  attachment  of  the  obturator  externus  mus- 
cle must  be  cut  from  the  digital  fossa  with  care. 

1.  Incise  in  several  places  the  cotyloid  ligament, 
so  that  air  can  enter  the  acetabulum.  Adduct  and 
forcibly  rotate  inward  the  joint,  partially  dislocating 
the  head  of  the  femur.  Divide  the  ligamentum  teres 
aofainst  the  head  of  the  femur,  when  the  dislocation 
is  easily  completed. 

Pass  a  chain-saw  around  the  neck  of  the  femur, 
and  saw  through  the  bone,  protecting  the  soft  parts. 


OPERATION'S  OR  THE  OSSEOUS  SYSTEM.         119 

The  acetabulum  is  readily  examined,  the  sides  of  the 
wound  beins:  retracted. 

2.  If  an  excision  is  to  include  the  division  of  the 
bone  just  above  the  level  of  the  lesser  trochanter, 
other  attachments  must  be  separated  before  the  head 
of  the  bone  is  dislocated.  Cut  the  periosteum  at  a 
right  angle  to  the  longitudinal  incision,  carrying  the 
knife  as  far  around  the  bone  as  possible.  This  hori- 
zontal incision  of  the  periosteum  should  be  on  the 
level  of  the  middle  of  the  trochanter.  Separate  all 
the  tissues  down  to  the  level  of  the  lesser  trochanter. 
Now  the  head  of  the  bone  is  to  be  dislocated,  and  the 
chain-saw  passed  behind  the  bone  above  the  lesser 
trochanter.  Divide  the  bone  just  above  the  level  of 
the  lesser  trochanter,  protecting  the  soft  parts  from 
contact  with  the  saw. 

Knee. — Place  the  subject  on  the  back,  with  the 
knee-joint  semi-flexed. 

Begin  an  incision  just  below  the  adductor  tuber- 
cle on  the  internal  condyle,  and  extend  it  across  the 
front  of  the  limb  below  the  patella  to  a  correspond- 
ing part  of  the  external  condyle  of  the  femur.  Di- 
vide all  the  tissues  to  the  bone,  opening  widely  the 
joint.  Flex  the  joint,  and  carefully  cut  the  crucial 
ligaments. 

The  lateral  ligaments  having  been  completely  di- 
vided against  the  condyles,  the  posterior  surface  of  the 
femur  is  readily  reached.  Separate  the  tissues  as  far 
back  as  the  posterior  surfaces  of  the  condyles,  protect- 
ing with  the  thumb  the  popliteal  artery.  Ketract  the 
tissues  and  divide  the  bone  by  means  of  a  Butcher's 
saw  from  behind  forward.  Do  not  remove  so  much 
bone  as  to  include  the  posterior  articular  surfaces  of 

9 


120        OPERATIVE  SURQERY  ON  THE  CADAVER. 

the  condyles,  nor  the  upper  portion  of  the  patellar 
articular  surface.  Saw  the  bone  horizontally  to  the 
surfaces  of  the  condyles,  and  not  to  the  axis  of  the 
bone ;  the  same  amount  of  bone  in  length  is  removed 
from  each  condyle,  thus  preserving  the  obliquity  of 
the  axis  to  the  plane  of  the  lower  end  of  the  femur. 

Separate  the  tissues  from  the  upper  end  of  the 
tibia  to  the  extent  of  one  half  inch.  Eetract  the 
tissues,  and,  by  means  of  a  Butcher's  saw,  divide  the 
bone  from  behind  forward.  The  saw  should  remove 
the  articular  surface  and  a  thin  layer  of  bone  at  a 
right  angle  to  the  long  axis  of  the  tibia.  The  section 
of  bone  is  above  the  level  of  the  head  of  the  fibula. 

Turn  upward  the  flap  containing  the  patella,  and^ 
by  making  parallel  incisions  toward  the  bone  begin- 
ning from  above,  enucleate  the  bone  from  its  capsule. 
By  putting  the  fingers  under  the  upturned  flap,  the 
patella  is  made  prominent  and  its  separation  expe- 
dited. 

Bring  the  sawn  surfaces  of  the  femur  and  tibia 
into  exact  apposition,  and  wire  them  together.  Sut- 
ure with  catgut  the  divided  ligamentum  patellae. 
Provide  drainage  from  the  pouch  above  the  bones  to 
the  lower  angles  of  the  wound.  Suture  the  deep 
tissues  (capsule)  together  by  means  of  buried  sutures 
of  catgut.  Close  the  external  wound,  providing  for 
drainage  from  the  superficial  parts  of  the  wound. 

Ankle-Joint, — Turn  the  leg  upon  its  inner  sur- 
face. 

Make  an  incision  three  inches  long  over  the  lower 
subcutaneous  portion  of  the  fibula,  down  along  the 
posterior  border  of  the  external  malleolus.  Extend 
the  incision  to  the  tip  and  up  along  the  anterior  bor- 


OPERATION'S  OR  THE  OSSEOUS  SYSTEM,         121 

der  of  tlie  malleolus.  Divide  all  tlie  tissues  against 
tlie  bone.  Separate  tlie  tissues  from  tlie  bone  up  to 
tlie  interosseous  space  by  means  of  an  elevator.  Pass 
a  wide  director  through  tlie  interosseous  space  to  pro- 
tect tlie  tissues  while  the  bone  is  sawn  by  means  of  a 
chain-saw.  Grasp  the  lower  sa\vn  end  of  the  fibula, 
and  separate  its  lower  and  internal  attachments, 
keeping  the  edge  of  the  knife  against  the  bone. 

Turn  the  leg  upon  its  outer  surface.  Make  an 
incision  three  inches  long  over  the  tibia  near  its  inner 
border,  extendins:  over  the  internal  malleolus  near  its 
posterior  border.  Continue  the  incision  over  the 
lower  to  the  anterior  border  of  the  malleolus.  Di- 
vide the  tissues  and  separate  them  from  the  bone  to  a 
level  above  the  joint.  Saw  the  internal  malleolus, 
and  complete  its  division  by  means  of  cutting  forceps. 
Kemove  the  internal  malleolus,  cutting  toward  the 
bone  to  avoid  the  tendons  and  vessels  in  close  prox- 
imity. Protrude  the  tibia  and  saw  off  its  articular 
surface. 

Push  the  astragalus  into  the  opening,  and  remove 
its  articular  surface  by  means  of  the  rongeur.  Ap- 
pose the  cut  end  of  the  astragalus  to  that  of  the  tibia. 


CHAPTEK  XI. 

AMPUTATIONS  AND  DISARTICULATIONS. 
MAITIPULATION    OF    THE    AMPUTATIN^G- KNIFE. 

1.  How  to  hold  the  Knife. — ^In  operating  grace- 
fully, several  methods  of  holding  tlie  amputating-knife 
are  practiced : 

(a)  The  knife  is  held  ordinarily  as  a  table-knife. 
This  method  was  discussed  as  practiced  with  the 
scalj^el. 

(h)  The  knife  is  held  with  the  handle  in  the  full 
grasp  of  the  hand.  If  the  edge  of  the  knife  be 
turned  from  the  palm  of  the  hand,  the  thumb  should 
be  placed  as  a  support  on  the  back  of  the  handle. 

(c)  The  handle  of  the  knife  near  its  extremity  is 
held  between  the  pulps  of  the  index  and  middle  fin- 
gers and  the  thumb.  The  extremity  of  the  handle 
can  be  made  to  describe  an  arc  in  the  space  between 
the  index-finger  and  thumb  without  touching  the 
palm  of  the  hand.  The  knife,  pointing  upward,  has 
its  edge  turned  toward  the  palm  of  the  hand. 

This  method  is  used  in  making  a  circular  incision 
around  a  limb. 

2.  How  to  cut  with  the  Knife. — In  cutting  with 
the  amputating-knife  the  blade  should  be  given  a  free 
sawing^  movement. 


AMPUTATION'S  AND  DISARTICULATIONS.         123 

When  the  knife  is  used  to  pierce,  its  point  should 
be  steadily  advanced ;  never  partially  withdrawn  and 
again  advanced,  because  the  first  thrust  may  have 
wounded  some  important  structure. 

STEPS    IN    OPEEATING. 

1.  Tissues  belonging  to  the  part  distal  to  the  site 
of  the  operation  must  be  left  in  continuity,  to  serve 
as  a  covering  for  the  wound-surface  caused  by  the 
amputation. 

(a)  Circular  Method. — In  this  method  one  or 
more  cellulo-cutaneous  flaps  are  raised  to  cover  the 
wounded  surface.  All  the  tissues  are  divided  at  a 
right  angle  to  the  long  .axis  of  the  limb  near  the  level 
of  the  base  of  this  cellulo-cutaneous  covering.  The 
soft  parts  are  divided  at  a  lower  level,  and  the  bone 
is  sacrificed  up  to  a  little  higher  level  than  the  base 
of  the  covering. 

{h)  Flap  Method— In  this  method  other  tissues 
besides  skin  and  subcutaneous  fascia  enter  into  the 
formation  of  the  covering  provided  for  the  wound- 
surface.  The  covering  may  be  formed  by  transfixion 
and  cutting  toward  the  surface,  or  by  cutting  from 
the  surface  toward  the  bone,  and  may  consist  of  one 
or  more  flaps. 

2.  Periosteal  Flap, — The  bone  is  provided  with  a 
covering  of  periosteum  for  its  sawn  surface  by  raising 
this  tissue  from  the  bone  to  be  sacrificed  before  ap- 
plying the  saw. 

(This  flap  is  made  to  prevent  the  atrophy  of  the 
end  of  the  bone ;  it  also  lessens  the  chance  of  an  ad- 
herent cicatrix.) 

3.  Interosseous  Flap, — Where  two  bones  are  to 


124       OPERATIVE  SURGERY  ON'  THE  CADAVER. 

be  sawn  tlirough,  the  tissues  between  should  be  di- 
\dded  transversely  at  a  level  one  half  inch  lower  than 
the  saw-cut,  and  then  separated  from  the  bones  up 
to  this  level. 

The  vessels  in  this  flap  are  easily  controlled. 

4.  The  bone  is  generally  removed  up  to  a  little 
higher  level  than  that  of  the  divided  soft  parts.  If 
the  bone  is  to  be  divided,  it  is  savm  off  ordinarily  at 
a  right  angle  to  the  long  axis  of  the  limb. 

The  sacrifice  of  the  soft  parts  is  not  necessarily  in 
fixed  proportion  to  that  of  the  hone, 

A^IPUTATIONS     AND     DISAETICULATIOIS^S     OF     THE    UPPER 

LIMB. 

Amputation  and  Disarticulation  of  Fingers, — 
During  all  the  operations  on  the  hand,  compress  the 
arteries  at  the  wrist.  The  three  rows  of  knuckles 
are  formed  by  the  heads  of  the  proximal  bones  en- 
tering^ into  the  articulations. 

Disarticulation  at  the  Distal  Phalanx. — Pronate 
the  hand.  The  finger  should  point  toward  the  opera- 
tor, and  be  held  between  his  thumb  above  and  his 
index-fing^er  beneath. 

Make  incisions  in  the  long  axis  of  the  finger  in 
the  middle  of  the  lateral  surfaces  which  begin  over 
the  expanded  base,  and  continue  downward  two 
thirds  of  the  length  of  the  phalanx.  Flex  the  joint 
to  a  right  angle,  and  join  the  proximal  ends  of  the 
lateral  incisions  by  a  dorsal  incision  over  the  line  of 
the  joint.  Open  the  joint  by  an  incision  slightly 
convex  toward  the  body,  and  divide  the  lateral  liga- 
ments. 

Pass  the  finger-knife,  with  its  edge  directed  to- 


AMPUTATIONS  AND  DISARTICULATIONS.         125 

ward  tlie  end  of  the  finger,  under  the  disarticulated 
base  of  the  phalanx.  Extend  the  finger  and  cut  the 
palmar  flap,  keeping  close  to  the  bone  and  following 
the  lateral  incisions.  Turn  the  edge  of  the  knife  per- 
pendicularly to  the  flap  and  cut  it  oif  from  the  pha- 
lanx. 

Kemove  any  portion  of  the  flexor  tendon  con- 
tained in  the  flap.  Occlude  the  digital  arteries. 
Close  the  wound  by  bending  the  palmar  flap  over  the 
end  of  the  second  phalanx.     Provide  for  drainage. 

Amputation  and  Disarticulation  of  the  Second  Phalanx. 

1.  Amjjyiutation. — Make  a  circular  incision  through 
the  integument  and  fascia,  as  near  the  end  of  the  pha- 
lanx as  possible.  Divide  the  flap  on  each  side,  so 
that  it  can  be  rolled  up  like  a  cuff  to  the  extent  of 
one  half  the  diameter  of  the  phalanx.  Divide  the 
tissues  circularly  at  the  level  of  the  base  of  the  flaps. 
Saw  the  bone  at  a  right  angle  to  its  long  axis. 

Occlude  the  digital  arteries.  Kound  off  the  an- 
gles of  the  fla23s,  and  stitch  the  flaps  accurately  to- 
gether, providing  for  drainage. 

2.  Disarticulation. — Make  two  lateral  incisions  as 
in  disarticulation  of  the  distal  phalanx.  In  making 
the  dorsal  incision,  divide  only  the  integument  and 
fascia  over  the  line  of  the  joint.  Elevate  a  flap,  in- 
cluding the  common  extensor  tendon  and  the  perios- 
teum, from  the  dorsal  surface  of  the  second  phalanx. 
This  flap  should  be  of  sufficient  size  to  cover  the 
head  of  the  phalanx.  Disarticulate  the  bones  and 
form  the  palmar  flap,  as  in  case  of  the  distal  phalanx. 

Occlude  the  digital  arteries.  Cover  the  head  of 
the   bone   with   the   periosteal   and   tendinous   flap, 


126        OPERATIVE  SURGERY  OR  TEE  CADAVER. 

wliicli  in  turn  must  be  covered  by  the  palmar  flap. 
Stitch  the  palmar  flap  to  the  tissue  on  the  dorsal  sur- 
face, making  the  sutures  in  such  a  manner  as  to  in- 
clude the  dorsal  tendon. 

Amputation  and  Disarticulation  of  the  Proximal  Phalanx. 

1.  Am'putation, — This  amputation  is  performed 
simiiarly  to  that  of  the  second  phalanx,  except  that 
a  dorsal  periosteal  and  tendinous  flap  should  be  se- 
cured of  sufficient  size  to  cover  the  sawn  end  of  the 
bone.  Stitch  the  dorsal  tendinous  flap  to  the  divided 
flexor  tendons.  Stitch  the  palmar  to  the  dorsal  flap^ 
providing  for  drainage. 

2.  Disarticulation, — This  operation  is  best  per- 
formed by  a  pyriform  incision.  The  other  fingers  are 
separated  from  the  one  to  be  removed. 

Begin  an  incision  on  the  dorsal  surface  at  the  an- 
terior extremity  of  the  head  of  the  metacarpal  bone, 
and  extend  it  obliquely  downward  toward  the  palmar 
surface,  one  quarter  of  an  inch  beyond  the  junction 
of  the  web  to  the  finger.  Make  a  similar  incision  on 
the  opposite  side  of  the  finger.  Join  the  ends  of  these 
incisions  by  a  transverse  incision  across  the  palmar 
surface  of  the  finger.  These  incisions  should  include 
the  tissues  to  the  bone.  Join  to  the  upper  angle  of 
this  pyriform  incision,  an  incision  three  quarters  of 
an  inch  long,  extending  along  the  dorsal  surface  of 
the  metacarpal  bone. 

Separate  the  tissues  from  the  bone,  without  pre- 
serving the  periosteum.  Open  the  joint  by  a  dorsal 
incision  concave  toward  the  body.  Divide  the  lateral 
ligaments,  and  disarticulate  the  bones.  Occlude  the 
digital  arteries. 


AMPUTATIONS  AND  DISARTICULATIONS,         127 

The  head  of  the  metacarpal  bone  is  often  removed 
when  symmetry  is  more  desirable  than  strength. 

In  the  case  of  the  thumb  or  the  index-iinger,  an 
external  flap  may  be  fashioned  to  cover  the  wonnd- 
surface,  and  an  internal  one  in  case  of  the  little 
finger. 

The  heads  of  the  second  or  fifth  metacarpal  bones 
should  be  cut  off  obliquely  toward  the  contiguous 
bone. 

The  practice  of  set  amputations  or  disarticula- 
tions of  the  metacarpal  bones  is  of  doubtful  expe- 
diency. In  amputating  through  these  bones  the  bases 
of  the  second,  third,  and  fifth  should  be  preserved, 
on  account  of  their  tendinous  attachments.  In  dis- 
articulating the  first  metacarpal  the  saddle-shape 
of  the  articulation  should  be  remembered,  and  the 
proximity  of  the  radial  artery.  The  sesamoid  bones 
should  not  be  included  in  the  flap. 

Disarticulation  at  the  Wrist, — Compress  the  bra- 
chial artery.     Supinate  the  hand. 

Begin  an  incision  at  the  styloid  process  of  the  ra- 
dius and  extend  it  straight  down  in  the  palm  of  the 
hand  to  within  one  half  inch  of  the  level  of  the  head 
of  the  second  metacarpal  bone.  Begin  a  second  incis- 
ion at  a  corresponding  point  on  the  ulnar  side  of  the 
wrist,  and  extend  it  into  the  palm  to  within  one  half 
inch  of  the  level  of  the  head  of  the  fifth  metacarpal 
bone.  Joiu  the  distal  ends  of  these  incisions  by 
means  of  a  transverse  incision  across  the  palm  of  the 
hand.  Divide  the  tissues  until  the  flexor  tendons  are 
encountered. 

Kaise  this  rectangular  flap  from  the  palm  up  to 
the  level  of  the  wrist-joint.     The  pisiform  bone  and 


128        OPEBATIYE  SUEQEBY  ON^  THE  CADAVER. 

the  unciform  jDrocess  of  tlie  unciform  bone  may  be 
cut  witli  bone-nippers,  and  afterward  dissected  from 
tlie  flap. 

Pronate  tlie  band,  and  connect  the  proximal  ends 
of  the  longitudinal  incisions  by  a  dorsal  incision 
sligbtly  convex  downward.  Reflect  this  short  dorsal 
cellulo-cutaneous  flap  to  the  level  of  the  wrist-joint. 

Grasp  the  hand  and  strongly  flex  the  wrist.  Di- 
vide the  extensor  tendons  and  open  into  the  joint  by 
an  incision  slightly  convex  toward  the  body.  Divide 
the  lateral  ligaments.  Retract  the  palmar  flap,  and 
divide  with  one  sweep,  not  pushj  of  the  knife,  all  the 
flexor  tendons. 

Cut  short  the  divisions  of  the  ulnar  and  median 
nerves.  Occlude  the  radial  artery,  and  any  small 
dorsal  or  palmar  arteries  which  may  be  seen.  The 
superficial  arch  is  included  in  the  palmar  flap.  The 
styloid  processes  may  be  nipped  off.  Stitch  the  pal- 
mar to  the  dorsal  flap,  providing  for  drainage. 

DiibreuiVs  Operation, — Make  a  flap  convex  down- 
ward, whose  base  shall  extend  from  the  junction  of 
the  outer  to  the  middle  third  of  the  wrist  anteriorly, 
to  a  corresponding  jDoint  on  the  dorsum.  The  lower 
convex  border  of  the  flap  extends  to  the  level  of  the 
head  of  the  first  metacarpal  bone.  Reflect  this  cel- 
lulo-cutaneous flap  up  to  the  level  of  the  wrist. 

Make  an  incision  from  one  extremity  of  the  base 
of  the  flap  around  the  ulnar  side  of  the  wrist  to  the 
other  extremity.  Retract  the  cellulo-cutaneous  tissue 
up  to  the  level  of  the  wrist,  and  remove  the  hand,  as 
already  described.  Occlude  the  radial  and  ulnar  ar- 
teries, and  fit  the  flap  to  the  surface  of  the  wound, 
providing  for  drainage. 


AMPUTATION'S  AND  DISARTICULATIONS.         129 

Annputation  through  the  Forearm  (circular). — 
Compress  tlie  brachial  artery.  Extend  the  arm  and 
hold  it  between  supination  and  pronation.  Measure 
the  circumference  of  the  forearm  at  the  site  of  the 
amputation.  The  length  of  the  flap  should  be  one 
quarter  of  this  measurement. 

The  operator,  standing  on  the  right-hand  side  of 
the  limb,  with  his  right  foot  forward,  and  stooping 
slightly,  should  carry  the  knife  under  and  up  on  the 
other  side  of  the  forearm  until,  by  extending  his 
wrist,  the  edge  of  the  knife  lies  horizontally  on  the 
upper  surface  of  the  limb.  With  a  slight  sawing 
motion  the  knife  is  made  to  divide  circularly  the  in- 
tegument and  cellular  tissue  around  the  limb.  As 
the  knife  cuts  under  the  limb  and  on  the  side  nearest 
to  the  operator,  the  handle  describes  an  arc  between 
the  index-finger  and  thumb,  so  that  at  the  comj)letion 
of  the  incision  it  points  forward.  The  operator  at 
the  same  time  assumes  the  erect  position. 

Elevate  the  flap,  keeping  the  edge  of  the  knife 
directed  perpendicularly  to  the  muscular  tissue.  Slit 
the  flap  in  a  line  corresponding  to  the  long  axis  of  the 
ulna,  so  that  it  may  be  rolled  up  like  a  cuff  to  the 
desired  extent.  Make  a  circular  division  of  the  mus- 
cles at  a  level  one  haK  inch  below  the  base  of  the 
flap.  With  a  catlin  form  an  interosseous  flap  as  al- 
ready described.    Form  periosteal  flaps  for  each  bone. 

Ketract  the  soft  parts  by  means  of  a  retractor, 
made  by  partially  tearing  into  three  strips  a  rather 
wide  bandage.  One  of  the  strips  should  go  between 
the  bones,  and  lie  over  the  other  strips  crossed  above. 
Grasp  with  the  left  hand  the  limb  just  above  the  pro- 
posed division  of  the  bone.     Saw  the  bones,  begin- 


130        OPERATIVE  SURGERY  ON   THE  CADAVER. 

nino;  and  ending:  on  tlie  more  fixed.  The  radius  is 
more  fixed  below,  and  the  ulna  above. 

Remove  any  spiculum  by  means  of  the  bone-nip- 
pers. Occlude  the  radial,  ulnar,  and  the  tw^o  inter- 
osseous arteries.  Remember  that  the  posterior  inter- 
osseous artery  lies  between  the  superficial  and  deep 
layer  of  muscles.  Provide  for  drainage,  and  stitch 
the  flap  accurately  together,  making  the  line  of  union 
vertical,  rounding  off  the  angles  of  the  flap  made  by 
the  ulnar  incision,  and  where  the  flap  is  doubled  upon 
itself  superiorly. 

In  the  middle  of  the  forearm  preserve,  if  possible, 
the  insei'tion  of  the  pronator  radii  teres  muscle,  and 
in  the  upper  part  the  insertions  of  the  biceps  and 
brachialis  anticus. 

Disarticulation  at  the  Elbow-Joint  (circular). — 
Extend  the  elbow  and  abduct  the  limb.  Compress 
the  brachial  artery  above  the  middle  of  the  arm. 

Measure  the  circumference  of  the  limb  around  the 
joint,  to  determine  the  length  of  the  flap.  Remem- 
ber that  the  line  of  the  articulation  is  oblique,  and  is 
fully  one  half  inch  below  the  internal  epicondyle. 

Make  a  circular  division  of  the  integument  and 
superficial  fascia,  as  described  in  the  last  operation. 
Raise  the  flap  and  roll  it  up  like  a  cuif  above  the 
joint.  Forcibly  extend  the  joint,  and  divide  the  tis- 
sues in  front  in  the  line  of  the  joint  obliquely  down- 
ward and  inward.  Divide  the  lateral  ligaments.  Hy- 
perextend  the  joint  and  dislocate  forward  the  olec- 
ranon. Retract  the  flap,  and  divide  with  a  sweep  of 
the  knife  the  triceps  tendon. 

Occlude  the  brachial  and  the  profunda  arteries. 
Pull  out  and  cut  short  the  median,  ulnar,  and  mus- 


AMPUTATION'S  AND  DISARTICULATIONS.         131 

culo-spiral  nerves.  Bring  tlie  flap  together  vertically^ 
and  round  off  the  superior  and  inferior  folded  angles. 
Stitch  the  apposed  edges,  providing  for  drainage. 

Awputation  through  the  Arm. — The  amputation 
through  the  arm  by  the  circular  method  is  per- 
formed by  following  the  same  general  rules  already 
described. 

This  amputation  should  also  be  practiced  by  the 
flap  method.  Compress  the  vessels  above  the  site  of 
the  proposed  amputation.  Abduct  and  rotate  out- 
v^ard  the  shoulder-joint.  Stand  on  the  right-hand 
side  of  the  limb. 

Grasp  the  arm  one  inch  below  the  proposed  level 
of  the  saw-cut,  between  the  left  thumb  and  index- 
finger.  The  thumb  should  be  placed  over  the  biceps, 
and  the  index-finger  over  the  triceps  muscle,  the  hu- 
merus being  situated  about  midway  between.  Begin 
an  incision  just  below  the  tip  of  the  index-finger,  and 
extend  it  downward  the  length  of  one  half  the  diame- 
ter of  the  limb.  Make  a  similar  incision  downward, 
from  just  below  the  tip  of  the  thumb.  Join  the 
lower  ends  of  these  incisions  by  a  transverse  incision 
somewhat  convex  downward.  These  incisions  should 
divide  the  integument  and  superficial  fascia,  which 
will  immediately  retract.  Complete  the  internal  flap 
by  beginning  at  the  level  of  the  retracted  integument 
to  cut  obliquely  to  the  bone  situated  between  the 
tips  of  the  thumb  and  index-finger. 

The  brachial  artery  may  be  caught  by  means  of 
forceps  as  soon  as  it  is  divided.  The  base  of  this 
internal  flap  thus  formed  includes  the  semi-circum- 
ference of  the  limb.  The  flap  includes  the  inner  bor- 
ders of  the  biceps  and  triceps  muscles. 


132        OPERATIVE  SURGERY  OJ^  THE  CADAVER. 

Througli  the  anterior  angle  of  tlie  wound  pusL. 
tlie  point  of  the  amputating-knife  across  the  outer 
surface  of  the  humerus — the  edge  of  the  knife  being 
directed  downward.  Advance  the  point  of  the  knife 
to  the  posterior  angle  of  the  wound,  the  tissues  being 
pressed  external  to  the  track  of  the  knife.  Carry  the 
knife  downward  along  the  external  surface  of  the  hu- 
merus with  a  free  sawing  movement,  supporting  the 
flap  with  the  left  hand.  When  the  knife  has  reached 
a  level  about  an  inch  below  the  extremity  of  the  in- 
ternal flap,  turn  its  edge  perpendicularly  toward  the 
surface,  and  form  the  extremity  of  the  external  flap 
by  cutting  directly  to  the  surface. 

Ketract  the  flaps,  and  form  a  periosteal  flap. 
Clear  the  bone,  being  sure  that  the  musculo-spiral 
nerve  is  divided.     Saw  through  the  bone. 

Occlude  the  brachial  and  the  two  profunda  arter- 
ies. Draw  upon  the  median,  ulnar,  and  musculo-spi- 
ral nerves,  and  cut  them  oif  at  the  wound-surface. 
Stitch  the  flaps  together,  providing  for  drainage. 

Disarticulation  at  the  Shoulder- Joint  (Spence). — 
Place  the  subject  near  the  edge  of  the  table,  with 
the  back  raised  upon  a  high  block.  Compress  the 
vessels  in  the  axilla  by  the  elastic  tubing,  as  already 
described.  Slightly  abduct  and  rotate  outward  the 
limb. 

Begin  an  incision,  as  for  resection  of  the  head  of 
the  humerus,  a  little  above  and  external  to  the  cora- 
coid  process,  and  extend  it  three  or  four  inches  down- 
ward in  the  axis  of  the  limb.  This  incision  should 
divide  the  tissues  down  to  the  bone,  uncovering  the 
tendon  of  the  long  head  of  the  biceps,  and  enabling 
the  operator  to  inspect  the  shoulder-joint. 


AMPUTATIONS  AND  DISARTICULATIONS.         133 

From  the  lower  end  of  this  incision  make  a  trans- 
verse incision  slightly  convex  downward,  dividing  all 
the  tissues  external  to  the  humerus  and  extendinir  to 
the  posterior  fold  of  the  axilla.  This  incision  cuts 
through  the  deltoid  muscle  just  above  its  insertion. 

Begin  a  second  incision  at  the  lower  end  of  the 
vertical  incision,  and  carry  it  transversely  and  slightly 
convex  downward,  around  the  inner  side  of  the  limb, 
to  meet  the  external  incision  at  the  posterior  axil- 
lary fold.  This  incision  should  only  divide  the  in- 
ternment and  the  subcutaneous  fascia. 

o 

Elevate  the  deltoid  portion  of  the  flap  up  to  the 
level  of  the  acromion  process.  Rotate  the  limb  in- 
w^ard,  and,  Avith  a  forcible  sweep  of  the  knife  above 
the  greater  tuberosity,  divide  the  capsule  and  the  ten- 
dons of  muscles,  opening  widely  the  joint.  Rotate 
the  limb  outward,  and  divide  the  capsule  of  the  joint 
and  the  tendon  of  the  subscapulars. 

Pass  the  knife  over  the  head  of  the  humerus  to 
its  inner  side.  Cut  downward,  following  the  humerus 
to  the  level  of  the  divided  integument  on  the  inner 
side  of  the  limb.  Place  the  thumb  between  the  flap 
and  the  humerus,  and  compress  the  axillary  artery 
against  the  fingers  of  the  same  hand  placed  in  the  ax- 
illa. Turn  the  edge  of  the  knife  perpendicularly  to 
the  flap  and  cut  straight  through  the  tissues  on  the 
inner  side  of  the  limb. 

amputatio:n^s  axd  disaeticulations   of   the  lower 

LIMB. 

Amputatio7is  and  Disarticulations  of  Toes, — Com- 
press the  vessels  of  the  leg  during  these  operations. 
The  rules  given  for  performing  the  amputations 


134       OPERATIVE  SURGERY  ON  THE  CADAVER. 

and  disarticulations  of  tlie  fingers  are  applicable  to 
tliose  of  the  toes.  Disarticulations  are  to  be  pre- 
ferred in  operating  on  the  toes,  with  the  one  excep- 
tion of  amputation  through  the  proximal  phalanx  of 
the  o^reat  toe. 

In  the  disarticulation  of  the  first  metatarso-phalan- 
geal  joint  the  pyriform  incision  should  cross  the  plan- 
tar surface  of  the  great  toe  at  least  one  half  inch  be- 
low the  web,  on  account  of  the  great  size  of  the  head 
of  the  metatarsal  bone.  It  is  preferable  to  remove 
the  heads  of  the  metatarsal  bones  after  disarticula- 
tions. 

Amputation  and  Disarticulation  of  Metatarsus. — 
1.  Amputation. — Grasp  the  toes  with  the  left  hand, 
and  stand  facing  the  sole  of  the  foot. 

Make  an  incision  through  the  soft  parts  from  one 
side  of  the  foot  to  the  other,  following  the  groove  at 
the  junction  of  the  toes  to  the  sole.  Join  to '  the 
ends  of  this  incision  two  lateral  incisions,  one  along 
the  inner  side  of  the  foot  over  the  first  metatarsal 
bone,  and  the  other  along  the  outer  side  of  the  foot 
over  the  fifth  metatarsal  bone.  These  lateral  incis- 
ions should  extend  to  the  level  of  the  proposed  ampu- 
tation through  the  metatarsus.  Reflect  the  plantar 
flap  thus  marked  out,  cutting  close  to  the  metatarsal 
bones. 

Eeflect  a  dorsal  cellulo-cutaneous  flap  inverse  in 
length  to  the  plantar  flap.  The  dorsal  flap  should  be 
slightly  convex  downward,  and  its  base  should  ex- 
tend from  one  side  to  the  other  of  the  base  of  the 
plantar  flap.  Divide  the  dorsal  tendons  at  the  level 
of  the  base  of  the  dorsal  flap. 

Incise  the  tissues  in  the  interosseous  spaces  to  al- 


AMPUTATION'S  AND  DISARTICULATIONS.         135 

low  four  strips  of  a  six-tailed  retractor  to  be  passed 
througli  the  spaces.  Ketract  tlie  flaps  and  the  tissues 
in  the  interosseus  spaces  and  saw  through  the  meta- 
tarsal bones. 

Cut  off  the  protruding  part  of  any  tendon  and 
stitch  the  plantar  to  the  dorsal  flap,  providing  for 
drainage. 

2.  Disarticulation, — Disarticulation  of  separate 
metatarsal  bones  should  be  performed  by  a  pyriform 
incision,  as  for  disarticulation  of  the  proximal  pha- 
lanx, supplemented  by  a  dorsal  incision  over  the  bone 
up  to  the  level  of  the  tarso-metatarsal  joint.  Avoid 
wounding  the  plantar  arch. 

In  disarticulating  the  first  tarso-metatarsal  joint, 
avoid  wounding  the  communicating  branch  between 
the  dorsalis  pedis  and  the  external  plantar  artery. 

Lisfrancs  Ojperation, — Extend  the  ankle  and 
grasp  the  sides  of  the  foot,  with  the  left  index-finger 
and  thumb  resting  over  the  bases  of  the  fifth  (tuber- 
osity)  and  first  metatarsal  bones.  The  base  of  the 
first  metatarsal  bone  is  situated  one  and  a  half  inch 
below  the  tubercle  of  the  scaphoid. 

Cut  a  dorsal  cellulo-cutaneous  flap  slightly  convex 
downward,  whose  base  shall  extend  to  the  middle  of 
the  sides  of  the  foot  at  the  level  of  the  tarso-metatar- 
sal articulations.     Eeflect  this  dorsal  flap. 

Grasp  the  toes  in  the  left  hand  and  flex  the  ankle, 
to  render  the  sole  of  the  foot  accessible.  Join  to  the 
ends  of  the  dorsal  incision  an  incision  extending  down 
the  sides  of  the  foot  and  across  the  sole  through  the 
center  of  the  balls  of  the  toes.  This  incision  divides 
all  the  soft  parts,  and  in  crossing  the  sole  is  on  a  level 
with  the  heads  of  the  metatarsal  bones.    The  incision 

10 


136       OPERATIVE  SURGERY  ON  THE  CADAVER. 

will  be  slightly  convex  downward  and  reach  a  lower 
level  internally  than  externally. 

Extend  the  ankle  and  bear  down  on  the  metatar- 
sal bones.  Divide  the  dorsal  tendons  at  the  level  of 
the  base  of  the  dorsal  flap.  Begin  the  disarticulation 
by  carrying  the  knife  around  the  tuberosity  of  the 
fifth  metatarsal  bone  to  its  inner  side,  where  its  ar- 
ticular surface  is  situated.  Disarticulate  in  a  line 
downward  and  inward  until  the  knife  is  arrested  by 
the  second  metatarsal  bone.  Disarticulate  from  the 
inner  side  the  first  tarso-metatarsal  joint. 

Pierce  with  the  knife,  having  its  edge  directed 
forward,  the  tissue  between  the  bases  of  the  first  and 
second  metatarsal  bones,  and,  by  making  the  handle 
of  the  knife  describe  an  arc  toward  the  ankle,  divide 
the  attachments  of  the  second  metatarsal  bone  to  the 
first  metatarsal  and  internal  cuneiform  bones.  The 
same  manoeuvre  is  practiced  on  the  other  side  of  the 
second  metatarsal  bone.  Divide  the  dorsal  ligament 
between  the  middle  cuneiform  and  the  base  of  the 
second  metatarsal  bone  by  making  transverse  parallel 
cuts  at  short  intervals  until  the  line  of  the  articula- 
tion is  found. 

All  resistance  is  now  overcome  and  the  articular 
surfaces  exposed.  Sever  the  inferior  attachments  to 
the  bones  together  with  the  insertion  of  the  peroneus 
lonoqis  into  the  base  of  the  first  metatarsal  bone. 

Pass  a  narrow-bladed  knife  behind  and  then  be- 
neath the  disarticulated  bases  of  the  metatarsal  bones 
and  cut  downward,  following  closely  the  bones  until 
the  plantar  flap  is  completed. 

The  lateral  arching  of  the  metatarsal  bones  is  de- 
stroyed by  this  disarticulation,  hence  the  knife  can 


AMPUTATIONS  AND  DISARTICULATIONS.         137 

follow  the  bones  wMle  piercing  tlie  foot  from  side  to 
side.  Occlude  tlie  dorsalis  pedis,  tlie  internal  plantar, 
and  external  plantar  arteries.  Stitcli  the  plantar  to 
the  dorsal  flap,  providing  for  drainage. 

Amputation  and  Disarticulation  tJirougJi  tlie  Tar- 
gy^,^. — 1.  Amputation, — Moliere  and  Hancock  recom- 
mend sawing  through  the  tarsus  without  considering 
the  line  of  the  articulations. 

Form  a  plantar  flap  of  large  size  and  an  inversely 
large  dorsal  flap,  following  Lisfranc's  operation  as  a 
model.  Make  the  section  of  the  bones  as  if  operating 
upon  a  single  bone. 

2.  Clwparfs  Operation  {Disarticulation  at  tlie 
Medio-tarsal  Joint), — Grasp  the  sides  of  the  extend- 
ed foot  just  posterior  to  the  tubercle  of  the  scaphoid 
and  over  a  point  one  inch  posterior  to  the  tuberosity 
of  the  fifth  metatarsal  bone  between  the  left  thumb 
and  index-finger.  Make  a  short  dorsal  cellulo-cuta- 
neous  flap  with  its  base  extending  to  the  middle  of 
the  lateral  surfaces  of  the  foot  at  the  points  over 
which  the  left  thumb  and  index-finger  are  applied. 
The  flap  should  be  slightly  convex  downward. 

Flex  the  ankle,  grasping  the  toes  to  present  the 
sole  of  the  foot  to  the  operator.  Join  the  ends  of  the 
dorsal  incision  by  an  incision  extending  down  the  sides 
of  the  foot  and  across  the  sole  just  posterior  to  the 
balls  of  the  toes.  This  incision  should  divide  all  the 
tissues  down  to  the  bones,  and  should  extend  across 
the  sole  about  one-half  inch  from  the  heads  of  the 
metatarsal  bones. 

Reflect  the  dorsal  flap.  Forcibly  extend  the  foot 
and  divide  the  dorsal  tendons  over  the  line  of  the 
articulations.     Disarticulate  the  bones  in  a  line  ex- 


138       OPERATIVE  SURGERY  ON^  THE  CADAVER. 

tending  across  tlie  tarsus  from  half  an  inch  below 
the  peroneal  tubercle  to  a  point  just  above  the 
tubercle  of  the  scaphoid. 

Pass  a  narrow-bladed  knife  between  the  disarticu- 
lated surfaces  and  turn  its  edge  toward  the  toes. 
Cut  the  plantar  flap,  keeping  close  to  the  bones. 

The  plantar  flap  is  often  fashioned  more  symmet- 
rically by  including  only  a  portion  of  the  tissues  in- 
ternally, making  the  internal  and  external  edges  of 
equal  thickness. 

Occlude  the  dorsalis  pedis,  internal  plantar,  and 
the  external  plantar  arteries. 

Disarticulation  at  the  Ankle- Joint  (^Syme's  Opera- 
tion),— Grasp  the  foot  with  the  left  hand  and  flex 
the  ankle  until  the  foot  is  at  a  right  angle  with  the 
leg. 

Begin  an  incision  at  the  tip  of  the  external  mal- 
leolus and  extend  it  downward  and  across  the  sole  of 
the  foot  to  a  corresponding  point  on  the  inner  side 
of  the  limb.  The  incision  will  terminate  at  a  point 
a  little  below  the  posterior  border  of  the  inner  mal- 
leolus, and  should  divide  all  the  tissues  to  the  bone. 

Connect  the  ends  of  this  incision  by  an  incision 
across  the  instep  in  a  line  which  bisects  the  angle 
made  by  the  foot  and  leg.  This  incision  should  only 
divide  the  skin  and  subcutaneous  fascia. 

Raise  the  heel-flap,  keeping  the  edge  of  the  knife 
always  directed  toward  the  os  calcis  and  using  the  left 
thumb  in  the  wound  to  push  back  the  flap.  Avoid 
wounding  the  posterior  tibial  artery.  Separate  the 
attachment  of  the  tendo  Achillis  and  reflect  the  flap 
over  the  tuberosity  of  the  os  calcis. 

Forcibly  extend  the  ankle,  and  having  raised  the 


AMPUTATIONS  AND  DISARTICULATIONS,         139 

skin  and  cellular  tissue,  cut  tlie  tendons  anteriorly  in 
tlie  line  of  tlie  joint.  The  bones  may  now  be  cleared 
at  a  level  just  above  the  ankle-joint  and  the  two  mal- 
leoli with  a  thin  slice  of  the  tibia  sawn  off  at  a  right 
angle  to  the  axis  of  the  leg. 

The  joint  may  be  disarticulated  by  dividing  the 
ligaments  anteriorly  and  around  the  malleoli,  and 
only  the  malleoli  sawn  off  obliquely  upward.  If  the 
joint  is  to  be  disarticulated,  it  may  be  done  before 
the  heel-flap  is  raised,  and  then  the  flap  separated 
from  above  downward. 

Occlude  the  anterior  tibial,  external  plantar,  and 
internal  plantar  arteries.  Cut  off  any  protruding 
tendon.  Make  a  longitudinal  slit  one  half  inch  long- 
through  the  posterior  thin  part  of  the  flap,  just  ex- 
ternal to  the  tendo  Achillis.  Cover  the  ends  of  the 
bone  with  the  heel-flap,  providing  for  drainage  on 
each  side  and  posteriorly. 

Pirogoff^s  Opei^ation, — Flex  the  ankle  so  that  the 
foot  is  brought  to  a  right  angle  with  the  leg. 

Make  an  incision  from  the  tip  of  one  malleolus 
across  the  sole  of  the  foot  to  the  tip  of  the  other 
malleolus  dividing  the  tissues  to  the  bone.  Join  the 
ends  of  this  incision  by  an  incision  across  the  instep, 
at  an  angle  of  45°  to  the  axis  of  the  leg,  dividing  the 
integument  and  cellular  tissue. 

Eeflect  the  short  dorsal  flap,  and  forcibly  extend 
the  ankle.  Divide  the  dorsal  tendons  and  disarticu- 
late the  joint. 

Separate  from  above  downward  the  tissues  from 
the  OS  calcis,  until  the  sustentaculum  tali  is  uncovered. 
Saw  the  os  calcis  obliquely,  from  just  behind  the 
astragalus  to  the  edge  of  the  incision  through  the  soft 


140        OPERATIVE  SURGERY  ON'  THE  CADAVER. 

parts  across  tHe  sole  of  tlie  foot.  Clear  tlie  bones  to 
a  level  just  above  tbe  joint,  and  saw  off  tbe  malleoli 
and  a  thin  slice  of  the  tibia. 

Occlude  the  anterior  tibial,  external  plantar,  and 
the  internal  plantar  arteries.  Cut  oif  any  protruding 
tendon.  Wire  the  retained  portion  of  the  os  calcis  to 
the  end  of  the  tibia.  Provide  for  drainage,  and  close 
the  wound  as  in  the  case  of  Syme's  operation. 

The  OS  calcis  may  be  sawn  through  from  below 
upward  and  backward,  the  dorsal  flap  raised,  and 
the  malleoli  sawn  off  without  disarticulating  the 
ankle. 

It  is  of  advantage  to  make  the  incision  across  the 
sole  more  anteriorly,  when  a  greater  portion  of  the 
OS  calcis  is  preserved  in  its  oblique  section. 

If  the  dorsal  and  plantar  incisions  are  made 
broadly  convex  downward  to  the  level  of  the  medio- 
tarsal  joint,  the  os  calcis  may  be  sawn  through  hori- 
zontally just  below  the  sustentaculum  tali,  as  recom- 
mended by  Le  Fort.  When  the  section  of  the  os 
calcis  is  complete,  the  joint  between  the  cuboid  and 
OS  calcis  is  disarticulated.  The  stump  has  a  broad 
base  already  accustomed  to  pressure. 

Amputations  through  the  Leg.  —  The  circular 
method  of  amputating  may  be  practiced,  the  rules  for 
which  have  already  been  considered. 

TeaMs  Operation, — Compress  the  vessels  above 
the  site  of  the  operation.  Stand  on  the  right  side  of 
the  limb.  Measure  the  circumference  of  the  limb  at 
the  proposed  site  of  the  amputation. 

Make  an  anterior  square  flap,  whose  sides  are 
equal  to  one  half  this  circumference.  (The  flap  will, 
of  course,  include  more  than  half  of  the  circumfer- 


AMPUTATION'S  AND  DISARTICULATIONS.         141 

ence  of  the  limb  below.)  Eeflect  the  flap,  which 
should  include  all  the  tissues  anterior  to  the  bones 
and  to  the  interosseous  membrane.  Avoid  nicking 
the  anterior  tibial  artery,  while  separating  the  tissues 
from  the  interosseous  membrane. 

A  periosteal  flai)  may  be  formed  for  the  tibia  and 
raised  with  the  anterior  flap. 

Connect  the  sides  of  the  anterior  flap  at  a  quarter 
of  its  length  from  its  base,  by  a  transverse  incision 
through  all  the  tissues  posterior  to  the  bones.  Ee- 
flect this  posterior,  rectangular  flap,  the  base  of  which 
is  one  half  and  the  length  one  eighth  the  circumfer- 
ence of  the  limb. 

Form  an  interosseous  flap,  and  retract  the  tissues 
by  means  of  a  three-tailed  retractor.  Clear  the  bones 
at  the  junction  of  the  flaps,  and  begin  the  section  of 
the  tibia  at  a  right  angle  to  its  long  axis.  Complete 
the  section  of  the  fibula  while  sawing  through  the 
tibia.  Some  prefer  the  section  of  the  fibula  at  a 
little  higher  level. 

Occlude  the  anterior  tibial,  the  posterior  tibial, 
and  the  peroneal  arteries.  Cut  ofl^  any  protruding 
tendon  and  pull  out  and  divide  the  anterior  tibial 
nerve  as  high  up  as  possible.  The  angle  formed  by 
the  crest  of  the  tibia  may  be  rounded  off  by  means  of 
bone-nippers.  Double  the  anterior  flap  upon  itself 
over  the  ends  of  the  bones,  and  stitch  together  the 
contiguous  edges  of  the  flaps,  providing  for  drainage. 

In  amputations  near  the  knee,  preserve  the  tuber- 
cle of  the  tibia,  and  avoid  opening  into  the  superior 
tibio-fibular  articulation,  which  may  communicate 
with  the  knee-joint. 

Disarticulation  at  the  Knee- Joint  (^Circular  Meth- 


U2       OPERATIVE  SURGERY  ON  THE  CADAVER. 

od), — Extend  the  knee,  and  compress  tlie  vessels 
above  tlie  site  of  tlie  operation. 

Form  a  circular,  cellulo-cutaneous  fiap,  the  length 
of  one  quarter  the  circumference  of  the  limb  over  the 
joint.  The  incision  will  be  made  about  one  inch  be- 
low the  level  of  the  tubercle  of  the  tibia.  Slit  the 
flap  posteriorly,  and  roll  it  upward  like  a  cuif. 

Flex  the  knee,  and  divide  the  ligamentum  patellae 
close  to  the  patella,  and  the  capsule  of  the  joint 
against  the  condyles  of  the  femur.  Sever  the  lateral 
ligaments  completely,  by  cutting  to  the  posterior  sur- 
face of  the  condyles,  and  divide  the  crucial  ligaments 
as  they  appear  in  the  interior  of  the  joint. 

Divide  from  behind  forward,  the  tissues  posteri- 
orly, against  the  upper  extremity  of  the  tibia,  about 
half  an  inch  below  the  level  of  the  joint.  Pass  the 
knife  through  the  joint  to  divide  the  posterior  liga- 
ment, and  direct  its  edge  downward  along  the  poste- 
rior surface  of  the  head  of  the  tibia,  to  complete  the 
operation. 

Occlude  the  popliteal  artery  and  vein.  Push  a 
director  into  the  synovial  pouch  above  the  patella, 
to  its  upper  and  inner  limit,  and  cut  do^Ti  upon  the 
end  of  the  director  to  make  an  opening  to  admit  a 
large  drainage-tube. 

Bring  the  edges  of  the  flap  together  antero-pos- 
teriorly ;  round  off  the  lower  angles  formed  by  slit- 
ting, and  the  upper  by  doubling  the  flap,  and  enter 
the  sutures  after  providing  for  drainage,  above  and 
below. 

Bav/len's  Ojyeration. — Extend  the  knee  and  con- 
trol the  vessels  above. 

Make  an  oval  incision  around  the  limb  from  one 


AMPUTATIONS  AND  DISARTICULATIONS.         143 

incli  below  the  tubercle  of  the  tibia  anteriorly,  to  one 
half  inch  above  the  level  of  the  head  of  the  tibia  pos- 
teriorly. The  incision  should  extend  almost  trans- 
versely across  the  limb  belov^,  so  as  to  form  a  broad 
end  to  the  flap,  - 

Reflect  the  flap  up  to  the  ligamentum  patellae. 
Semiflex  the  knee,  and  divide  the  ligamentum  patel- 
lae, the  capsule,  and  the  lateral  ligaments,  to  open 
widely  the  joint.  Sever  the  crucial  ligaments.  Pass 
the  knife  between  the  ends  of  the  bones  and  divide 
the  tissues  posteriorly,  cutting  downward  and  then 
backward. 

Occlude  the  popliteal  artery  and  vein.  Provide 
for  drainage  from  the  joint-cavity  above,  and  internal 
to  the  patella,  as  in  the  last  operation.  Cover  the 
end  of  the  femur  with  the  flap,  and  stitch  the  edges 
of  the  wound  together,  providing  for  drainage. 

Amputations  through  the  Thigh  ( Cardenas  Opera- 
tion).— Control  the  vessels  above,  and  extend  the 
knee-joint ;  stand  on  the  right-hand  side  of  the  limb. 
Grasp  the  femur  over  the  condyles  between  the  left 
index-finger  and  thumb. 

Begin  an  incision  through  the  skin  and  cellular 
tissue  at  the  posterior  and  lower  border  of  the  con- 
dyle, over  which  the  index-finger  rests,  and  extend  it 
downward,  in  a  broad,  convex  curve,  below  the  pa- 
tella, and  then  upward  to  a  corresponding  point  over 
the  other  condyle,  over  which  the  thumb  has  been 
placed.  The  end  of  the  flap  should  extend  to  the 
tubercle  of  the  tibia,  and  should  be  very  broad.  Re- 
flect the  flap  up  to  the  ligamentum  patellae.  Flex 
the  knee-joint,  and  divide  the  ligamentum  patellae, 
the  capsule  of  the  joint,  and  the  lateral  ligaments. 


144        OPERATIVE  SURGERY  ON'  THE  CADAVER. 

The  joint  can  now  be  examined,  as  was  tlie  case 
after  tlie  first  incision  of  Spence's  operation  at  the 
shoulder. 

Sever  the  crucial  ligaments.  Pass  the  knife 
through  the  joint,  then  extend  the  joint,  and  divide 
the  tissues  posteriorly,  cutting  directly  backward, 
thus  forming  no  posterior  flap.  (The  operation  is 
often  modified  by  forming  a  short  posterior  flap.) 

Grasp  the  end  of  the  femur  by  means  of  lion- 
forceps  and  saw  the  bone  through  the  condyles.  The 
bone  may  be  sawn  through  without  disarticulating 
the  posterior  tissues,  being  cut  from  behind  forward. 
The  patella  may  be  dissected  out  of  its  capsule. 

Occlude  the  popliteal  artery  and  vein  by  separate 
ligatures.  Close  the  wound,  providing  for  drain- 
age. 

Gritti's  Operation, — A  rectangular  flap,  instead  of 
a  convex  flap,  is  fashioned  from  the  front  of  the 
limb  as  in  Garden's  operation.  The  femur  is  di- 
vided just  above  the  condyles,  and  the  cartilaginous 
surface  of  the  patella  is  sawn  oif. 

The  sawn  surface  of  the  patella  is  applied  to  that 
of  the  femur,  as  in  Pirogoff 's  osteo-plastic  operation  at 
the  ankle. 

Circular  Method.  —  This  method  of  amputation 
should  be  practiced,  following  the  rules  already  dis- 
cussed. The  muscles  should  be  divided  fully  an  inch 
below  the  base  of  the  flap,  on  account  of  their  great 
contraction. 

Lister'^s  Operation. — Control  the  vessels  of  the 
thigh,  above  the  site  of  the  operation.  Extend  the 
limb.  Measure  the  circumference  of  the  thigh  at  the 
site  of  the  proposed  amputation. 


AMPUTATION'S  AND  DISAETICULATIONS.        145 

Eaise  an  anterior  convex  flap,  consisting  of  integu- 
ment, and  a  moderately  tliick  layer  of  muscular  tis- 
sue, tlie  length  of  two  thirds  the  measurement  of  the 
circumference  of  the  limb.  Keflect  a  posterior  cel- 
lulo-cutaneous  con^^ex  flap,  one  third  the  circumfer- 
ence of  the  limb  in  length. 

Divide  the  remainder  of  the  soft  parts  circularly. 
Provide  a  periosteal  flap  and  retract  the  tissues  about 
two  inches.  Saw  the  bone.  Occlude  the  femoral 
and  profunda  arteries. 

Esmarcli^s  Operation. — Raise  two  lateral  flaps  of 
moderate  length.  Divide  all  the  soft  parts  circularly 
to  the  bone.  Push  up  the  periosteum  to  the  extent 
of  an  inch  or  more,  and  saw  through  the  bone. 

Suture  the  periosteal  flap  over  the  end  of  the 
bone,  and  then  the  muscles  together  by  means  of 
buried  sutures.  Suture  the  flaps  together,  making 
no  provision  for  drainage. 

Disarticulation  at  the  Hi^J- Joint — Bring  the  nates 
over  the  edge  of  the  table ;  control  the  vessels  as  de- 
scribed by  means  of  the  elastic  tubing  (Lloyd). 

JordavJs  Operation, — Hold  the  thigh  at  an  angle 
of  45°  with  the  axis  of  the  body.  Begin  an  incision 
three  inches  above  the  middle  of  the  upper  border  of 
the  great  trochanter,  and  continue  it  downward,  along 
the  outer  surface  of  the  thigh,  dividing  all  the  tissues 
to  the  bone.  Separate  the  periosteum  from  the  bone 
down  to  the  proposed  level  of  division  of  the  soft 
parts  (Oilier). 

Disarticulate  the  hip-joint  as  in  resection.  Divide 
the  soft  parts  by  the  circular  method  at  as  low  a 
level  as  possible.  Occlude  the  femoral  and  profunda 
arteries. 


146        OPERATIVE  SURGERY  ON  THE  CADAVER. 

This  metliod  of  amputating  is  applicable  to  the 
shoulder- joint. 

Transfixion  {Li&ton), — Place  the  subject  so  that 
the  nates  project  beyond  the  table.  Abduct  the  op- 
posite limb,  and  lift  up  the  scrotum.  Slightly  flex 
the  hip-joint,  and  rotate  the  limb  inward. 

On  the  left  side  transfix  the  tissues  in  front  of 
the  joint,  from  a  point  midway  between  the  anterior 
superior  spine  of  the  ilium  and  the  great  trochanter, 
to  a  point  anterior  to  the  tuberosity  of  the  ischium. 
Guard  against  piercing  through  the  foramen  ovale. 
On  the  light  side,  the  point  of  the  knife  is  entered 
anterior  to  the  tuber  ischii. 

Cut  downward,  following  the  bone  closely,  for 
five  or  six  inches.  (An  assistant  can  now  jDass  his 
fingers  under  the  flap,  and  press  the  vessels  against 
his  thumbs,  placed  over  the  flap.)  Turn  the  edge  of 
the  knife  perpendicularly  to  the  flap,  and  cut  directly 
to  the  surface. 

Abduct  and  rotate  strongly  outward  the  joint. 
The  capsule  may  have  been  opened  by  the  first 
thrust  of  the  knife.  Divide  the  capsule,  and  par- 
tially dislocate  the  head  of  the  femur,  when  the  liga- 
mentum  teres  can  be  divided,  and  the  disarticulation 
completed. 

Pass  the  knife  behind  the  head  of  the  bone.  Ad- 
duct  and  rotate  inward,  when  the  trochanter  major 
will  not  interfere  with  the  formation  of  a  posterior 
flap  four  or  ^n^  inches  in  length. 

(Guthrie  cuts  the  flaps  from  the  surface  toward 
the  bone.) 

Occlude  the  femoral  vessels,  the  profunda,  the  ob- 
turator, and  sciatic  arteries. 


IITDEX. 


Abdominis,  paracentesis,  12. 
Adductor  longus,  tenotomy  of,  72. 
Amputation  of  arm,  131. 

of  forearm,  129. 

of  leg,  140. 

of  metatarsus,  134. 

of  penis,  63, 

of  proximal  phalanx,  126. 

of  second  phalanx,  125. 

of  tarsus,  134. 

of  thigh,  143. 

of  toes,  133. 
Ankle,  disarticulation  at,  138. 
Antrum,  perforation  of,  34. 
Arm,  amputation  through,  131. 
Arteriotomy,  101. 
Artery,  ligation  of  axillary,  82. 

brachial,  81. 

common  carotid,  85. 

external  carotid,  88. 

internal  carotid,  87. 

deep  epigastric,  94. 

facial,  89. 

femoral,  93. 

gluteal,  92. 

common  iliac,  90. 

external  iliac,  94. 

internal  iliac,  92. 

lingual,  89. 

occipital,  90. 

dorsalis  pedis,  100. 

peroneal,  99. 

popliteal,  97. 

internal  pudic,  93. 

radial,  80. 

sciatic,  93. 

subclavian,  83. 

temporal,  90. 

superior  thyroid,  88. 

anterior  tibial,  99. 

posterior  tibial,  98. 

ulnar,  81. 

vertebral,  84. 
Aspiration  (Dieulafoy),  15. 


Aural  specula  (Gruber  and  Toynbee),  1. 
Axillary  artery,  ligation  of,  82. 

Bauden's  operation,  142. 
Bones,  wiring  of,  105. 
Bougies,  oesophageal,  5. 

rectal,  8. 
Brachial  artery,  ligation  of,  81. 
Bronchotomy,  37. 

Canalization,  20. 

Garden's  operation,  143. 

Carotid  artery,  ligation  of  common,  85. 

external,  88. 

internal,  87. 
Castration,  65. 
Catheterization  of  Eustachian  canal,  3. 

of  larynx,  4. 

of  urethra,  5, 

of  posterior  urethra,  61. 
Catheter,  tunneled,  7. 
Chopart's  operation,  137. 
Circumcision,  62. 
Colectomy,  49. 
Colostomy,  lumbar,  49. 
Compression  of  vessels,  76. 
Corneal  paracentesis,  10. 
Cystotomy,  lateral  perineal,  58. 

median  perineal,  57. 

suprapubic,  60. 

Disarticulation  at  ankle-joint,  138. 

at  elbow,  130. 

at  hip,  145. 

at  knee,  141. 

at  metatarsus,  134. 

of  distal  phalanx,  124. 

of  proximal  phalanx,  126. 

of  second  phalanx,  125. 

of  tarsus,  137. 

of  toes,  133. 

of  wrist,  127. 
Drainage,  20. 
Dubreuil's  operation,  128. 


148 


INDEX. 


Elbow,  disarticulation  at,  130. 
Enterectomy,  46. 
Enterorrhaphy,  46. 

Enterostomy,  with  enterotomy  or  en- 
terectomy, 48. 
Enterotomy,  47. 

Epigastric  artery,  ligation  of  deep,  94. 
Esmarch's  operation,  145. 
Eustachian  catheter  (Noyes),  3. 
Excision  of  breast,  43. 

of  eye,  32. 

of  inferior  maxilla,  109. 

of  superior  maxilla,  lUG. 

of  tongue,  35. 
Extensor  communis  digitorum,  tenoto- 
my of,  69. 

longus  digitorum  pedis,  tenotomy  of, 
70. 

quadriceps  femoris,  tenotomy  of,  71. 

primi  and  secundi  internodii  pollicis, 
69. 
Extraction  of  teeth,  32. 
Eye,  excision  of,  32. 

Facial  artery,  ligation  of,  89. 
Fasciatomy,  plantar  fascia,  72. 
Femoral  artery,  ligation  of,  95. 
Flexor  cubiti,  tenotomy  of  biceps,  69. 

carpi  radialis,  tenotomy  of,  69. 

carpi  ulnaris,  tenotomy  of,  69. 

longus  and  brevis  digitorum,  tenoto- 
my of,  69. 

profundus   digitorum,  tenotomy  of, 
68. 

sublimis  digitorum,  tenotomy  of,  68. 

biceps  femoris,  tenotomy  of,  71. 

biceps  femoris,  suture  of  tendon,  72. 

pollicis  longus,  tenotomy  of,  68. 
Forearm,  amputation  through,  129. 

Gluteal  artery,  ligation  of,  92» 
Gritti's  operation,  144. 

Hip,  disarticulation  at,  145. 
Hypodermic  needle,  15. 

Iliac  artery,  ligation  of  common,  90. 

external,  94. 

internal,  92. 
Intubation  of  larynx  (O'Dwyer's  tubes), 
4. 

Joint,  resection  at  ankle,  120. 
elbow,  114. 
hip,  118. 
knee,  119. 

metacarpo-phalangeal,  117. 
phalangeal,  117. 


Joint,  resection  at  shoulder,  112. 

wrist,  115. 
Jordan's  operation,  145. 

Knee,  disarticulation  at,  141. 

Knife,   manipulation    of    amputating, 

122. 
Knot,  reef,  27. 
surgeon's,  27. 

Laparotomy,  median,  44. 
Laryngotomy,  38. 
Laryngo-tracheotomy,  39. 
Larynx,  catheterization  of,  4. 

intubation  of  (O'Dwyer's  tubes),  4. 
Leg,  amputation  through,  140. 
Ligaments,  shortening  of  round,  64. 
Ligation  of  arteries,  80. 

of  vessels,  77. 
Lingual  artery,  ligation  of,  89. 

nerve,  neurotomy  of,  73. 
Lisfranc's  operation,  135. 
Lister's  operation,  144. 
Listen's  operation,  146. 

Mammary  gland,  excision  of,  43. 
Maxilla,  excision  of  superior,  109. 

of  inferior,  106. 
Median  nerve,  suturing  of,  74. 
Metatarsus,  amputation  and  disarticu- 
lation of,  134. 

Nares,  plugging  of  posterior,  8. 
Nasal  duct,  probing  of,  4. 

specula  (Fraenkel),  1. 
Needle,  hypodermic,  15. 
Nephrectomy,  52. 
Nephrorrhaphy,  51. 
Nephrotomy,  52. 

Neurectomy  of  spinal  accessory,  73. 
Neurotomy  of  lingual,  73. 
Nerve,  stretching  of  great  sciatic,  74. 

suturing  of  median,  74. 

Occipital  artery,  ligation  of,  90. 
(Esophageal  probang  or  bougie,  5. 
Q']sophagotoray,  external,  41. 
Oophorectomy,  65. 
Operations,  steps  in,  123. 
Osteotomy,  104. 

Paracentesis  abdominis,  12. 
cornese,  10. 
pericardii,  11. 
thoracis,  11. 
tympani,  10. 
urcthroe,  14. 
vesicae,  12. 


INDEX. 


149 


Pedis,  ligation  of  dorsalis,  100. 
Penis,  amputation  of,  68. 
Pericardii,  paracentesis,  11. 
Perineal  cystotomy,  lateral,  58. 

cystotomy,  median,  5V. 

urethrotomy,  external,  54. 
Peroneal  artery,  ligation  of,  99. 
I'eroneus  longus  and  brevis,  tenotomy 

of,  '70. 
Phalanx,  disarticulation  of  distal,  124. 

proximal,  126. 

second,  125. 
Pharyngotomy,  42. 
Phlebotomy,  100. 
Pirogoff's  operation,  139. 
Plantar  fascia,  fasciatomy  of,  72. 
Popliteal  artery,  ligation  of,  97. 
Probing  nasal  duct,  4. 
Pudic  internal  artery,  ligation  of,  93. 

Eadial  artery,  ligation  of,  80. 
Rectal  bougie,  8. 

specula,  3. 
Resection  at  ankle,  120. 

bones,  articulating  ends,  112. 

elbow,  114. 

hip,  118. 

knee,  119. 

metacarpo-phalangcal,  117. 

phalangeal,  117. 

of  rib, 111. 

of  scrotum,  61. 

shoulder,  112. 

wrist,  115. 
Rib,  resection  of.  111. 

Saw,  manipulation  of,  1 03. 
Scalpel,  manipulation  of,  17. 
Sciatic  artery,  ligation  of,  93. 

nerve,  great,  stretching  of,  74. 
Scrotum,  resection  of,  61, 
Semimembranosus  and  semitendinosus, 

tenotomy  of,  71. 
Shoulder  (Spence),  disarticulation   at, 

132. 
Sounding  for  stone,  55. 
Sounds,  tunneled,  7. 
Specula,  aural  (Gruber,  Toynbee),  1. 

nasal  (Fraenkel),  1. 

rectal,  3. 

vaginal  (Fergusson's,  Sims' s),  2. 
Spinal  accessory,  neurectomy  of,  73. 
Sterno-cleido  -  mastoid,    tenotomy    of, 

67. 
Stomach-tube,  5. 
Stone,  sounding  for,  55. 
Strabismus,  30. 
Subclavian  artery,  ligation  of,  83. 


Suprapubic  cystotomy,  60. 
Suture,  continuous  or  glover's,  21. 

Czerny's,  27. 

double  continuous,  26. 

Gely's,  25. 

interrupted,  21. 

Jobert's,  26. 

Lembert's,  24. 

quilled,  22. 

quilt  or  fold,  23. 

twisted,  23. 
Syme's  operation,  138. 
Symphysiotomy,  52. 
Syringe,  aural,  1. 

rectal,  3. 

Tarsus,  amputation  and  disarticulation 

through,  137. 
Teale's  operation,  140. 
Teeth,  extraction  of,  32. 
Temporal  artery,  ligation  of,  90. 
Tendo  Achillis,  tenotomy  of,  70. 
Tendon  suturing,  flexor  biceps  femoris, 

72. 
Tenotome,  manipulation  of,  67. 
Tenotomy  of  adductor  longus,  72. 

of  flexor  carpi  radialis,  69. 

of  flexor  carpi  ulnaris,  69. 

of  flexor  biceps  cubiti,  69. 

of  extensor  communis  digitorum,  69. 

of   flexor  longus  and   brevis  digito- 
rum, 69. 

of    flexor   sublimis   and    profundus 
digitorum,  68. 

of  extensor  longus  pedis  digitorum, 
70. 

of  flexor  biceps  femoris,  71. 

of  quadriceps  extensor  femoris,  71. 

of  longus  hallucis,  69. 

of  peroneus  longus  and  brevis,  70. 

of  flexor  longus  pollicis,  68. 

of  primi  and  secundi  internodii  pol- 
licis, 69. 

of     semitendinosus    and    semimem- 
branosus, 71. 

of  sterno-cleido-mastoid,  67. 

of  tendo  Achillis,  70. 

of  tibialis  anticus,  70. 

of  tibialis  posticus,  70. 
Thigh,  amputation  through,  143. 
Thoracis,  paracentesis,  11. 
Thyroid   artery,  ligation  of   superior, 

88. 
Thyrotomy,  37. 
Tibialis  artery,  ligation  of  anterior,  99. 

anticus,  tenotomy  of,  70. 

posterior  artery,  ligation  of,  98. 

posticus,  tenotomy  of,  70. 


150 


INDEX. 


Toes,   amputation  and  disarticulation 

of,  V6Z. 
Tongue,  excision  of,  35. 
Torsion  of  vessels,  77. 
Tracheotomy,  39. 
Transfusion,  101. 
Trephining,  28. 

Tunneled  sounds  or  catheters,  7. 
Tympani,  paracentesis,  10. 

Ulnar  artery,  ligation  of,  81. 
Urethra,  catheterization  of,  5. 
paracentesis  of,  14. 


Urethrotomy,  perineal  external,  54. 

Vaginal  specula  (Fergusson's,  Sims's), 

2. 
Vertebral  artery,  ligation  of,  84. 
Vesicae,  paracentesis,  12. 
Vessels,  compression  of,  76. 

ligation  of,  77. 

torsion  of,  77. 

Wiring  of  bones,  105. 
Wrist,  disarticulation  at,  127. 


THE    END. 


October,  1887. 


MEDICAL 


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HAMMOND  (W.  A.).  Clinical  Lectures  on  Diseases  of  the  Nervous  System. 
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M.  D.     8vo.     Cloth,  $3.50. 

HART  (D.  BERRY).  Atlas  of  Female  Pelvic  Vnatomy.  With  Preface  by 
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descriptive  text.     Large  4to.     Cloth,  $15.00.     {Sold  only  })y  siihseripiion.) 

HARVEY  (A.).     First  Lines  of  Therapeutics.     12mo.     Cloth,  $1.50. 

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Vienna.     Second  enlarged  and  improved  edition.     8vo.     Cloth,  $2  00. 

HOWE  (JOSEPH  W.).  Emergencies,  and  how  to  treat  them.  Fourth  edition, 
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HOWE  (JOSEPH  W.).  The  Breath,  and  the  Diseases  which  give  it  a  Fetid 
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12mo.     Cloth,  $1.00. 

HUEPPE  (FERDINAND).  The  Methods  of  Bacteriological  Investigation. 
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Biggs,  M.  D.     Illustrated.     8vo.     Cloth,  $2.50. 

HUXLEY  (T.  H.).  The  Anatomy  of  Vertebrated  Animals.  Illustrated.  12mo. 
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HUXLEY"  (THOMAS  HENRY).  The  Anatomy  of  Invertebrated  Animals 
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JONES  (II.  MACNAUGHTON).  Pra(*.tical  Manual  of  Diseases  of  Women  and 
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KEYES  (E.  L.).  The  Tonic  Treatment  of  Syphilis,  including  Local  Treatment 
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LITTLE  (W.  J.).  Medical  and  Surgical  Aspects  of  lu-Knee  (Genu- Valgum) : 
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Surgical  Operation.  Illustrated  by  upward  of  Fifty  Figures  and  Diagrams. 
8vo.     Cloth,  $2.00. 


5 

LORING  (EDWARD  G.).  A  Text-Book  of  Ophthalmoscopy.  Part  1.  The 
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13 1  lllustratioiit^,  and  4  Chrorao-Lithographs.     8vo.     Cloth,  $5.00. 

LUSK  (WILLIAM  T.).  The  Science  and  Art  of  Midwifery.  With  246  Illustra- 
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LUYS  (J.).  The  Brain  and  its  Eunctions.  With  Illustrations.  12rao.  Cloth, 
$1.50. 

MARKOE  (T.  M.).  A  Treatise  on  Diseases  of  the  Bones.  With  Illustrations. 
8vo.     Cloth,  $4.50. 

MAUDSLEY  (HENRY).  Body  and  Mind  :  an  Inquiry  into  their  Connection 
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iology and  Pathology  of  the  Mind."     12mo.     Cloth,  $2.00. 

MAUDSLEY  (HENRY).    Pathology  of  the  Mind.    Third  edition.    12mo.    Cloth, 

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MAUDSLEY  (HENRY).     Responsibility  in    Mental   Disease.      12mo.     Cloth, 

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and  Pneumogastric  Nerves.     12mo.     Cloth,  $1.50. 

NEUMANN  (rSIDOR).  Hand-Book  of  Skin  Diseases.  Translated  by  Lucius 
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author's  Additions  and  Revisions  in  the  eighth  and  last  German  edition. 
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6 

PEYER  (ALEXANDER).  An  Atlas  of  Clinical  Microscopy.  Translated  and 
edited  bv  Alfred  C.  Girard,  M.D.  First  American,  from  the  manuscript 
of  the  second  German  edition,  with  Additions.  Ninety  Plates,  with  105 
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POMEROY  (OREN  D.).  The  Diagnosis  and  Treatment  of  Diseases  of  the  Ear. 
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Cloth,  $3.00. 

POORE  (C.  T.).  Osteotomy  and  Osteoclasis,  for  the  Correction  of  Deformities 
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QUAIN  (RICHARD).  A  Dictionary  of  Medicine,  including  General  Pathology, 
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RANNEY  (AMBROSE  L.).  Applied  Anatomy  of  the, Nervous  System,  being  a 
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Interest  and  Practical  Utility,  designed  for  Use  as  a  Text-Booh  and  as  a  Work 
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merous Illustrations.     l'2mo.     Cloth,  $1.00. 

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WYLIE  (WILLIAM  G.).  Hospitals:  Their  History,  Organization,  and  Con- 
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